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COLLEGE  OF 

PHYSICIANS  AND  SURGEONS 

LIBRARY 


Casino  Book  C 

M.  C.  WYMAN, 
Manager, 
1374  -  1376  Broadwaj 
New  York.'      I 


A  CLINICAL  TEXT-BOOK 


MEDICAL  DiAaFOSIS 


PHYSICIANS  AND  STUDENTS 


BASED  ON  THE  MOST  RECENT  METHODS  OF  EXAMINATION. 


BY 


OSWALD  VIERORDT,  M.D., 


PROFESSOR  OF  MEDICINE  AT  TUE  UNIVERSITY  OP  HEIDELBERG, 

FORMERLY  PRIVAT-DOCENT  AT  THE  UNIVERSITY  OP  LEIPZIG  ;  LATER,   PROFESSOR  OP  MEDICINE 

AND  DIRECTOR  OF  THE  MEDICAL  POLYCLINIC  AT  THE  UNIVERSITY  OP  JENA. 


AUTHORIZED  TRANSLATION, 

WITH    ADDITIONS, 


BY 

FRANCIS  H.  STUART,  A.M.,M.D., 

MEMBER  OF  THE  MEDICAL  SOCIETY  OF  THE   COUNTY  OF  KINGS,   NEW  YORK  ;  FELLOW  OF  THE 
NEW  YORK  ACADEMY  OP  MEDICINE,  MEMBER  OF  THE  BRITISH  MEDICAL  ASSOCIATION,  ETC. 


THIRD  REVISED  EDITION. 

WITH  ONE  HUNDRED  AND  SEVENTY-EIGHT  ILLUSTRATIONS, 

Many  of  which  are  in  colors. 


PHILADELPHIA: 
W.     B.     SAUNDERS, 

925   Walnut  Street. 
1894. 


'lev 


Entered  according  to  the  Act  of  Congress,  in  the  years  1891,  1893,  by 

W.    B.    SAUNDERS, 

in  the  Office  of  the  Librarian  of  Congress,  at  Washington. 


Press  of 
W.  B.  Saunders,  Philadelphia. 


VORWORT  DES  AUTORS  ZUR  ENGLISCHEN  AUFLAGE. 


Es  gereicht  mir  zur  lebhaften  Genugthuung,  Herrn  Francis  H. 
Stuart,  M.D.,  meinen  Dank  daftir  auszusprechen,  dass  er  es  unter- 
nommen  hat,  meine  Diagnostik  in  das  Englische  zu  dbersetzen 
Ich  bezweifle  nicht,  dass  die  Ubersetzung  ihm  gut  gelungen  ist, 
und  gebe  ihr  den  Wunsch  mit  auf  den  Weg,  dass  sie  sich  in  der 
neuen  Welt  ebenso  viele  Freunde  erwerben  moge,  wie  die  deutsche 
Ausgabe  in  Deutschland  gefunden  bat. 

Heidelberg,  SOsten  M'arz,  1891. 

Prof.  Dr.  0.  VIERORDT, 

Director  der  Poliklinik. 


(iii) 


TRANSLATOR'S   PREFACE   TO   THE   THIRD   EDITION. 


The  rapid  sale  of  the  second  edition,  which  was  quite  large,  has 
enabled  the  Translator  to  subject  his  work  to  another  careful  re- 
vision. For  the  correction  of  many  slight  errors  and  suggestions 
of  improvement  he  is  indebted  to  Professor  George  Dock  of  the 
University  of  Michigan,  who  was  a  pupil  of  the  Author,  and  who 
uses  the  work  as  a  text-book  in  his  classes. 

The  Translator  desires  to  express  his  gratification  that  this  valu- 
able work  of  Professor  Vierordt  has  met  in  its  English  dress  such 
universal  welcome  and  appreciation.  This  generous  reception  by 
the  profession  has  been  a  reward  for  his  labor,  and  a  stimulus  to 
him  to  make  the  work  still  more  Avorthy  of  its  popularity. 

FRANCIS    H.  STUART. 

123  JoRALEMON  Street,  Brooklyn,  N.  Y., 


TRANSLATOR'S  PREFACE. 


The  work  of  which  a  translation  is  here  offered  is  one  of  the  best 
that  has  yet  been  written  upon  the  subject.  When  it  first  came  into 
the  hands  of  the  translator  he  had  no  thought  of  ever  using  it  except 
as  a  work  of  reference.  But  as  he  read  it  he  became  convinced  that 
it  had  such  merit  that  it  would  certainly  be  welcomed  by  a  large  class 
of  readers  if  it  were  rendered  into  English.  Accordingly,  after  com- 
municating with  the  author  and  his  publisher,  the  work  of  translation 
was  begun,  and  has  been  prosecuted  at  such  intervals  of  time  as  could 
be  secured  from  an  active  professional  life.  If  the  work  shall  com- 
mend itself  to  others  as  it  has  to  him,  the  translator  will  feel  amply 
rewarded  for  the  effort  he  has  made  to  put  it  into  their  hands. 

Here  and  there  slight  additions  have  been  made,  which  the  trans- 
lator trusts  will  increase  the  value  of  the  work.  A  very  full  index 
has  been  prepared,  which,  it  is  believed,  comprises  a  reference  to 
every  material  statement  in  the  book. 

The  translation  was  almost  completed  when  a  copy  of  the  second 

edition  of  the  original  Avas  received  from  the  publisher.     The  author 

has  made  numerous  additions  which  have  enhanced  its  value,  and  the 

translation  has  been  made  to  correspond  with  this  enlarged  edition. 

It  is  gratifying  to  the  translator  to  find  that  a  second  edition  has  so 

soon  been  called  for,  and  that  his  own  favorable  opinion  has  been 

further  confirmed  by  the  fact  that  Italian  and  Russian  translations  of 

the  work  have  been  made. 

FRANCIS  H.  STUART. 

123  JoRALEMON  Street,  Brooklyn,  N.Y., 
March,  1891. 

(V) 


AUTHOR'S  PREFACE  TO  THE  SECOND  EDITIO:^. 


IjST  this  edition  the  book  has  received,  as  I  think,  not  incon- 
siderable additions  and  improvements.  To  mention  only  the  most 
important  ones  :  The  section  upon  the  examination  of  the  contents 
of  the  stomach  has  been  almost  entirely  rewritten,  and  so  have  some 
portions  of  the  section  on  the  examination  of  the  organs  of  the  senses, 
especially  that  of  the"  eye.  The  laryngoscopic  examination  of  the 
larynx  has  been  treated  anew,  and  much  more  extensively  than  in  the 
first  edition.  A  short  section,  almost  entirely  new,  has  been  added 
upon  the  enlargement  of  the  vessels  of  the  brain,  and  at  the  end 
of  the  book  a  concise  presentation  of  those  peculiarities  of  micro- 
organisms whose  recognition  and  discrimination  are  made  possible 
by  cultures  and  inoculation.  Finally,  with  the  hearty  cooperation 
of  the  publisher,  the  illustrations  of  the  most  important  micro- 
organisms are  printed  in  colors,  and  also  some  entirely  new  figures 
have  been  added. 

I  am  indebted  to  the  friendly  assistance  of  Professor  Gartner 
in  the  department  of  bacteriology,  of  which  I  here  make  public 
acknowledgment. 

OSWALD  VIERORDT. 

Jena,  August,  1889. 


vi) 


PREFACE  TO  THE  FIRST  EDITION. 


The  book  which  is  here  offered  to  the  medical  public  was  under- 
taken at  the  solicitation  of  a  number  of  associates,  and  in  view  of  the 
experience  which  I  have  acquired  during  more  than  four  years  of  work 
as  Teacher  of  Diagnosis  in  the  Medical  Clinic  at  the  University  of 
Leipsic.  Originally  I  had  in  view  a  very  extensive  treatise  com- 
prising a  detailed  explanation  of  normal  and  pathological  anatomy 
and  physiology  as  a  foundation  for  diagnosis.  But  this  plan  I 
abandoned  with  a  view  to  the  convenience  and  general  usefulness 
of  the  book. 

Regarding  the  principles  which  have  guided  me,  and  which  I  hope, 
particularly  in  the  "  Special  Part,"  notwithstanding  the  brevity  of  the 
presentation,  have  been  made  plain,  I  may  be  permitted  here  to 
specify  the  following.  I  have  here,  as  well  as  in  my  teaching,  taken 
pains  to  emphasize  that,  besides  availing  ourselves  of  the  constantly- 
increasing  finer  methods  of  diagnosis,  the  simple  use  of  our  senses, 
especially  of  the  unaided  eye,  must  not  be  forgotten.  Still  more  the 
manifold  labors  with  the  microscope  and  in  the  laboratory  ought  not 
to  permit  the  physician  to  forget  that  a  preparation  or  a  chemical 
reaction  is  not  enough  for  a  diagnosis,  but  that  the  whole  organism 
must  always  be  brought  under  consideration.  In  other  words,  in 
diagnosis  as  well  as  therapeutics  this  rule  is  imperative :  We  must 
individualize  the  case.  Should  the  book  to  any  extent  antagonize 
the  inclination  of  our  time  to  theorizing,  it  would  afford  me  especial 
satisfaction. 

OSWALD  VIERORDT. 

Leipsic,  June^  1888. 

(vii)     , 


CO:^TENTS. 


PART   I, 


CHAPTER  I. 

INTRODUCTION. 

rAGE 

Anamnesis        ............      18 

Mode  of  Taking  the  Anamnesis 19 

What  the  Anamnesis  Comprises .20 

Previous  History  of  the  Patient ...      20 

The  Present  Disease .      22 

CHAPTER  II. 

EXAMINATION   OF   PATIENTS, 

What  the  Examination  Comprises  . 24 

[Note  by  the  Translator  upon  Keeping  Records  of  Cases,  and  a  Form 
for  Recording  the  Results  of  a  Medical  Examination]         ...      24 


PART    II 


CHAPTER  III. 

GENERAL   EXAMINATION 

I.  The  Psychical  Condition  of  the  Patient  . 
II.  The  Position  of  the  Patient 

III.  The  Structure  of  the  Body  and  Nutrition 

IV.  Skin  and  Subcutaneous  Cellular  Tissue    . 

A.  The  State  of  Nutrition  of  the  Skin  . 

B.  The  Moisture  of  the  Skin  ;  Perspiration 


31 
31 
33 
36 
36 
36 


(ix) 


5  CONTENTS. 

PAGE 

C.  The  Color  of  the  Skin 38 

1.  The  Pale  Skin 39 

2.  Abnormal  Redness  of  Skin 41 

3.  The  Blue-red  Skin,  Cyanosis 42 

4.  The  Yellow  Skin,  Icterus,  Jaundice 45 

5.  The  Bronze  Skin 48 

6.  The  Cray  Skin  of  Silver  Deposit       .....  49 

D.  Other  Pathological  Appearances  of  the  Skin  which  are  of 

General  Diagnostic  Value 49 

1.  Acute  Exanthematous  Diseases          .        .         ...  49 

2.  Exanthemata  from  Poisons  and  the  Use  of  Medicines      .  50 

3.  Hemorrhages  in  the  Skin 51 

4.  Scars 52 

E.  CEdema    of   the    Skin    and    Subcutaneous    Cellular    Tissue 

(CEdema,  Anasarca)         .......  52 

F.  Emphysema  of  the  Skin 55 

V.  The  Temperature  of  the  Body.     Fever 57 

1.  The  Terms  Used  and  the  Method  of  Taking  the  Temperature  57 

2.  The  Normal  Temperature  of  the  Body     .        .         ...  59 

3.  Elevated  Temperature.     Fever         .        .         .         .         .        .60 

4.  The  Subnormal  Temperature    .        ,         .        .        .        .        .63 

5.  Diagnostic  Value  of  the  Temperature,  especially  of  its  General 

Course 64 

6.  Local  Elevation  or  Lowering  of  the  Temperature   ...  71 


PART    III. 


CHAPTER  IV. 

EXAMINATION  OF  THE   RESPIRATORY  APPARATUS. 

Examination  of  the  Nose  and  Larynx 73 

1.  The  Nose 73 

2.  The  Larynx  . 74 

Examination  of  the  Lungs      . 76 

Topographical  Anatomy  of  the  Lungs 76 

The  Anatomical  Boundaries  of  the  Lungs  with  Reference  to  the 

Thorax 77 

Inspection  of  the  Thorax 81 

1.  Normal  Form  of  Thorax  and  Normal  Respiration        .        .  81 

2.  Pathological  Forms  of  Thorax 83 

3.  Anomalies  of  Respiration      ...         ,        ...  89 


CONTENTS.  xi 

PACE 

Palpation  of  the  Thorax 100 

1.  Pain  caused  by  Pressure  upon  the  Thorax    ....  101 

2.  Testing  the  Movement  during  Respiration    ....  102 
General  and  Preliminary  Remarks  Regarding  Percussion        .        .  103 

1.  History  and  Methods 104 

2.  Qualities  of  Sounds 106 

3.  The  Conditions  that  determine  the  Quality  of  the  Sounds 

and  their  Production  in  the  Body.     The  Feeling  of  Re- 
sistance       ..........  109 

4.  Topographical  Percussion :  Determining  the  Parietal  Bound- 

aries of  Organs    .........  116 

Percussion  of  the  Thorax,  Especially  of  the  Lungs        .         .         .  118 

1.  Methods 118 

2.  Normal  Sound  over  the  Lungs,  Trachea,  and  Larynx.    The 

Normal  Boundaries  of  the  Lungs 119 

3.  Abnormal  Sound  over  the  Lungs.     Abnormal  position  of 

the  Border  of  the  Lungs 125 

The  Second  Quality  of  Sound  which  is  found  over  Diseased 

Lungs 130 

Auscultation  of  the  Lungs- 138 

1.  History.     The  Sphere  of  Auscultation  at  the  Present  Time  138 

2.  Methods  of  Auscultation 138 

3.  Auscultatory  Signs  in  Normal  Respiration   ....  141 

4.  Pathological  Sounds  in  the  Respiratory  Apparatus       .        .  144 
Palpation  of  Vocal  Fremitus  (Auscultation  of  the  Voice)       .        .  156 

Exploratory  Puncture  of  the  Pleura 160 

Methods  of  Measuring  and  Stethography 162 

Measuring  the  Thorax 162 

Spirometry,  Pneumatometry,  and  Stethography       ....  163 

Cough  and  Expectoration 164 

Expectoration,  Sputum 167 

1.  General  Characteristics  of  the  Expectoration       .         .        .  168 

2.  Foreign  Substances  in  the  Sputum  which  are  Visible  to  the 

Unaided  Eye 171 

3.  Microscopical  Examination  of  the  Sputum  ....  175 

CHAPTER  V. 

EXAMINATION  OF  THE  CIECULATOEY  APPARATUS. 

Examination  of  the  Heart 191 

Anatomy  of  the  Normal  Heart 191 

Preliminary  Remarks  necessary  to  Understand  the  Physical  Phe- 
nomena of  the  Heart 193 


xii  CONTENTS. 

PAOB 

Inspection  and  Palpation  of  the  Region  of  the  Heart     .        .        .  197 

The  Apex-beat 197 

Alteration  in  the  Width  and  Strength  of  the  Apex-beat  .        .  200 

The  Neighborhood  of  the  Heart  in  general       ....  202 

The  Epigastrium 204 

Percussion  of  the  Heart 204 

Normal  Percussion  Figure  of  the  Heart 205 

Methods  of  Percussion 205 

Enlargement  of  the  Area  of  Heart-dulness       ....  208 

Diminution  or  Loss  of  Heart-dulness 210 

Displacement  (dislocation)  of  the  Heart-dulness       .         .        .  210 

Auscultation  of  the  Heart 211 

Method  and  Normal  Condition 211 

Pathological  Changes  in  the  Heart-sounds        ....  216 

Organic  Endocardial  Heart-murmurs 221 

Inorganic,  Anaemic  Murmurs.     (Synonyms  :  accidental,  blood 

murmurs.) 229 

Pericardial  Murmurs.     [Friction-sounds.]         ....  230 

Examination  of  the  Arteries 234 

I.  The  Pulse,  its  Palpation  and  Graphic  Representation          .        .  234 

Palpation  of  the  Pulse 234 

1.  The  Normal  Pulse 234 

2.  Pathological  Frequency  of  the  Pulse     ....  237 

3.  Want  of  Rhythm  of  the  Pulse 241 

4.  Quality  of  the  Pulse 241 

6.  Symmetry  of  the  Radial  Pulse       .        .        .        .        .  245 

II.  Other  Phenomena  in  Arteries 253 

Examination  of  the  Veins 260 

Inspection  and  Palpation  of  Veins 260 

1.  Increased  Fulness  of  Veins 260 

2.  Phenomena  of  Circulation  in  the  Jugular  Veins  .        .         .  262 

3.  Phenomena  of  Circulation  in  Other  Veins    ....  267 

4.  Venous  Thrombosis 268 

Auscultation  of  Veins 268 

Examination  of  the  Blood 270 

Preliminary  Remarks 270 

1.  Color  and  Spectroscopic  Character  of  the  Blood  .        .        .  270 

2.  Microscopic  Examination  of  the  Blood        ....  273 

CHAPTER  VI. 

EXAMINATION  OF  THE  DIGESTIVE  APPARATUS. 

Mouth,  Palate,  and  Pharyngeal  Cavity 284 

Examination  of  the  CEsophagus .  291 


CONTENTS.  xiii 

PAGE 

Examination  of  the  Stomach 297 

Anatomy  of  the  Stomach 297 

Inspection  and  Palpation  of  the  Stomach 299 

Percussion  of  the  Stomach        . 304 

Auscultation  of  the  Stomach 307 

Examination  of  the  Intestines         .         .......  308 

Inspection  and  Palpation          .        .        .        .        .        .        .        .  308 

Percussion  of  the  Intestine 311 

Auscultation  of  the  Intestine 312 

Examination  of  the  Peritoneum      .        .        .        .        .         .                 .  312 

Inspection  of  the  Abdomen 313 

Examination  of  the  Liver \        .  319 

Inspection  of  the  Liver 320 

Palpation  of  the  Liver .  323 

Percussion  of  the  Liver 326 

Examination  of  the  Spleen 332 

Inspection  of  the  Spleen 334 

Palpation  of  the  Spleen 334 

Percussion  of  the  Spleen 336 

Auscultation  of  the  Spleen 339 

Examination  of  the  Pancreas,  Omentum,  Retro-peritoneal  Glands         .  340 

Examination  of  the  Contents  of  the  Stomach 341 

Examination  of  the  Process  of  Digestion 342 

Stomach-digestion  and  its  Disturbances 342 

Mode  of  Procedure  in  Examining  the  Stomach-digestion         .  347 

Vomiting,  and  the  Examination  of  What  is  Vomited    ....  358 

The  Vomit 359 

Animal  Parasites 377 

CHAPTER  VII. 

EXAMINATION   OF   THE   URINARY   APPARATUS. 

Examination  of  the  Kidneys 392 

Anatomy 392 

Local  Examination  of  the  Kidneys 394 

Pathological  Conditions  of  the  Kidneys 394 

Examination  of  the  Ureters  and  Bladder 398 

Examination  of  the  Urine 399 

(A)  Normal  Urine 401 

(B)  Pathological  Urine 406 

Sediments  of  Organic  Bodies,  or  Direct  Products  of  These  .  416 

Inorganic  Sediments 428 

Examination  of  the  Urinary  Constituents  in  Solution  .         .  433 

Bile-pigments  and  Bile-acids 442 

The  Urine  as  Affected  by  Medicines 460 


xiv  CONTENTS. 

CHAPTER  VIII. 

EXAMINATION   OF   THE   NEBVOUS   SYSTEM. 

PAGE 

Anatomy ;  Normal  and  Pathological  Physiology    .....  452 

1 .  The  Cortico-muscular  Tract  (the  Pyramidal  Tract,  Flechsig)      .  452 

2.  The  Sensitive  or  Centripetal  Tracts 459 

3.  Centres  and  Tracts  of  the  Special  Senses 460 

4.  Remarks  upon  the  Vessels  Supplying  the  Brain  ....  461 
Symptomatology  and  Methods  of  Examination 463 

Examination  of  the  Seat  of  Disease 463 

The  Spinal  Column 467 

The  Peripheral  Nerves  and  their  Surroundings        ....  468 

Examination  of  the  Condition  of  the  Mind 469 

Disturbances  of  Sensibility 472 

1.  Sensitiveness  to  Peripheral  Irritation 472 

[a)  Sensibility  of  the  Skin 473 

[b]  Deep  Sensibility 479 

The  Knowledge  of  Form  (Stereognosis) 481 

2.  Sensible  Phenomena  of  Irritation  and  Pain  from  Pressure  upon 

Nerves 482 

1.  Parsesthesia 482 

2.  Spontaneous  Pain 482 

3.  Distribution  of  the  Sensory  Cutaneous  Nerves    ....  484 
Disturbances  of  Motility 488 

1.  Paralysis 488 

2.  Disturbance  of  the  Nutrition  and  Tone  of  the  Muscles      .        .  489 

3.  The  Reflexes 495 

1.  Skin  Reflex 495 

2.  Tendon  Reflexes  (periosteal,  fascial  reflex)   ....  497 

4.  Electrical  Examination  of  the  Nerves  and  Muscles    .         .        .  501 

Regarding  the  Physics,  and  the  Instruments  Employed  '.  .  501 
Methods  of  Examination  and  their  Physiological  Results  upon 

the  Living  Human  Body .  505 

General  Methods,  and  Explanation  of  the  Terms  Employed  in 

Galvanic  Examinations 506 

Method  of  Examination  in  Detail.     Normal  Condition   .        .  507 

1.  Points  of  Stimulation 508 

2.  Examination 510 

(a)  Faradic  Examination     .         . '       .        .        .        .  512 

[b)  Galvanic  Examination 515 

3.  What  to  Observe  in  Determining  the  Electrical  Re- 

action      516 

Faradic  Current 517 

Galvanic  Current 517 


CONTENTS.  XV 

PAGE 

1.  The  Reaction  of  Degeneration  (EaE) 619 

(a)  Complete  EaR       .        . 619 

[b)  Partial  EaR .619 

Varieties  of  EaR 523 

(e)  Mixed  Electrical  Reaction 523 

2.  Myotonic  Reaction  (Erb) 524 

3.  Diagnostic  Value  of  the  Electrical  Condition       .         .         .  524 

4.  Mechanical  Excitability  of  Muscles  and  Nerves  .         .         .  526 

5.  Coordination  and  Ataxia 527 

6.  Spasms  of  the  Voluntary  Muscles         .....  530 

7.  Voluntary  Muscles,  their  Innervation,  their  Function,  and 

the  Diseases  that  Disturb  Them 536 

Disturbances  of  Speech  (Lalopathy) 548 

I.  Dysarthria  and  Anarthria 548 

II.  Aphasic  Disturbances,  Disturbance  of  Graphic  Communica- 
tion (of  Mimicking  and  Singing) 549 

Mode  of  Procedure  in  Testing  for  Aphasic  Disturbances         .         .  555 

Sense  Organs 561 

Disturbances  of  the  Vegetative  System  in  Nervous  Diseases  .        .        .  575 

1.  General  Phenomena 575 

2.  Disturbances  of  the  Respiratory  Apparatus          .        .        .  575 

3.  Disturbances  in  the  Circulatory  Apparatus  ....  576 

4.  Disturbances  of  the  Digestive  Apparatus      ....  577 

5.  Disturbances  of  the  Urinary  Apparatus        .       ■ .        .        .  579 

6.  Disturbances  of  the  Genital  Apparatus         ....  580 

7.  Disturbances  of  the  Skin 581 

Bones  and  Joints 583 

The  Diagnostic  Value  of  the  Symptoms  in  Nervous  Diseases         .  583 


APPENDIX. 

1.  Laryngoscopic  Examination  of  the  Larynx 589 

Paralysis  of  the  Muscles  of  the  Larynx 597 

2.  Examination  with  the  Ophthalmoscope 600 

3.  Bacteria  which  come  under  Consideration  in  the  Diagnosis  of  In- 

ternal Diseases 602 


MEDICAL  DIAGNOSIS. 


PART    I. 


CHAPTER    I. 


INTRODUCTION. 


The  physician  arrives  at  an  opinion  regarding  his  patient  in  two 
ways :  by  inquiry  of  the  patient  or  of  friends  of  the  patient,  and  by 
his  own  objective  examination.  The  result  of  the  former  is  called  the 
Anamnesis ;  the  latter  reveals  the  Present  Condition  of  the  Patient. 
The  notes  which  the  physician  makes  from  time  to  time  in  the  course 
of  his  continued  observation  of  the  patient,  and  in  which  he  records 
the  changing  phenomena  of  the  disease,  constitute  the  History  of  the 
Case. 

The  judgment  formed  in  this  way  is  expressed  by  the  Diagnosis. 
In  a  narrow  sense  such  a  judgment  simply  consists  in  giving  a  name 
to  the  disease  that  is  found;  or,  if  there  are  several  diseases  together, 
or  special  complications  of  one,  names  to  several  diseases.  But  in  the 
wider  sense,  a  diagnosis  must  always  consist  of  something  more  than 
this.  The  physician  must  endeavor  to  form  a  clear  conception,  in  a 
given  case,  as  to  how  the  whole  organism  has  been  affected  from  the 
beginning,  what  is  the  character  of  the  disease,  or  what  harm  it  has 
wrought  already  in  the  organism  as  a  whole,  as  well  as  locally.  If 
in  the  narrow  sense  the  diagnosis  is  schematic,  so  that  the  disease 
can  be  classified,  then  the  diagnosis  is  in  a  broader  sense  indi- 
vidualized. A  complete,  exhaustive  presentation  of  the  peculiarity 
and  severity  of  the  existing  disease  and  of  the  patient's  prospects 

•2  (17) 


J 8  MEDICAL  DIAGNOSIS. 

(Prognosis)  is  presented  only  by  this  method.  This  alone  is  a  sure 
guide  in  treatment. 

We  attain  to  a  diagnosis  in  this  wider  sense  only  by  having  our 
perception  of  the  general  behavior  of  patients  quickened  and  by 
carefully  combining  with  it  the  experience  derived  from  previous 
examinations. 

Since  the  chief  object  of  this  work  is  the  teaching  of  the  examination 
of  patients  and  the  presentation  of  the  methods  of  conducting  it,  we 
begin  with  but  a  very  few  words  in  regard  to  obtaining  the 

Anamnesis. 

What  is  it  necessary  for  the  physician  to  know,  beyond  what  his 
examination  reveals,  in  order  to  recognize  a  given  disease  in  itself  and 
to  form  a  critical  judgment  regarding  the  patient  in  a  larger  sense  ? 
It  is  difficult  to  define  this.  Facts  which  appear  insignificant  in 
themselves  in  experience  often  exercise  a  decided  influence  upon  the 
special  diagnosis,  and  especially  in  forming  a  judgment  regarding 
the  constitution  of  the  patient,  or  upon  the  timely  recognition  of  a 
secondary  disease.  From  having  at  hand  clear  knowledge  of  the 
symptoms  of  the  different  diseases,  both  of  their  remote  or  predisposing 
and  of  their  directly  exciting  causes,  the  physician  is  constantly  able 
to  select  what  is  essential  from  the  past,  and  so  to  avoid  too  great 
prolixity.  But  it  is  always  well  for  the  beginner  to  secure  as  com- 
plete an  anamnesis,  or  prior  history,  as  possible,  in  order  that  he  may 
allow  nothing  of  importance  to  escape  his  attention. 

The  anamnesis  generally  begins  with  and  involves  the  question  as 
to  whether  the  disease  is  acute  or  chronic,  what  organs  are  affected, 
or  are  inclined  to  be  diseased.  This  determines  the  examination  to 
follow,  in  that  certain  organs  are  examined  with  greater  exactitude 
than  others.  But  the  examiner  must  guard  himself  from  too  great 
influence  or  prejudice  from  the  result  of  the  anamnesis  ;  the  objectivity 
of  the  objective  examination  must  be  kept  in  view ;  and  this,  in  turn, 
may  give  occasion  for  supplementing  the  anamnesis,  by  occasioning 
additional  inquiries  regarding  certain  occurrences  and  appearances, 
and  thus  a  conclusion  is  finally  reached.  It  is  advisable  for  the 
student,  under  all  circumstances,  with  all  the  patients  he  examines, 
and  for  the  physician  at  least  with  his  more  important  cases,  to  note 


INTRODUCTION.  19 

down  in  regular  order  the  results  both  of  the  anamnesis  and  of  his 
examination.     [See  Translator's  note,  page  24  et  seq.~\ 

Mode  of  Tahing  the  Anam^iesis. 

First,  we  always  note  the  name,  occupation,  age,  residence  of  the 
patient.  Then  we  conduct,  as  simply  as  possible,  a  dialogue  with  the 
patient,  or  in  the  case  of  a  child  or  of  a  person  who  is  insensible, 
unconscious,  or  mentally  disturbed,  with  his  neighbors  or  relatives. 
How  much  we  may  allow  them  simply  to  tell,  how  much  we  must 
learn  by  asking  questions,  must  depend  upon  the  cultivation  and 
intelligence  of  the  person  who  is  giving  the  information.  We  must 
particularly  guard  against  asking  the  patient  leading  questions — that 
is,  influencing  his  reply  by  the  manner  in  which  we  put  the  questions. 
To  the  question :  "  Have  you  then  really  never  had  any  pain  in  the 
bowels  ?"  or,  "  Did  you  never  have  any  pain  in  the  bowels?"  we  shall 
almost  certainly  receive  an  affirmative  answer,  either  from  indiiference, 
or  from  a  desire  to  make  his  complaints  as  interesting  as  possible  and 
enlarge  upon  them  ;  or,  lastly,  whether  because  he  is  of  a  very  impres- 
sionable nature,  and  the  mere  calling  to  mind  the  question  of  pain 
suggests  to  him  what  in  reality  he  has  not  had. 

On  the  other  hand,  we  must  exercise  close  scrutiny  of  what  we 
learn,  a  scrutiny  which  it  is  generally  best  not  to  allow  the  patient  to 
know  of.     This  scrutiny  may  be  made  with  reference  to  three  points : 

(a)  We  must  not  accept  without  further  inquiry  the  name  the 
patient  gives  to  a  disease  he  has  formerly  passed  through,  since  mis- 
chief is  often  done  by  the  laity  in  the  use  of  the  names  of  diseases, 
as  of  diphtheria,  typhus,  etc.  In  any  doubtful  case  we  inquire  its 
symptoms,  and  also  what  the  physician  who  attended  the  patient  had 
called  the  disease. 

(b)  The  simulation  of  a  disease  is  common.  This  was  confined  in 
large  part  to  the  domain  of  hysteria ;  but,  now-a-days,  from  certain 
social  reasons,  it  is  much  more  frequent.  Neuralgia,  rheumatism, 
trembling,  spasms,  lameness,  also  pains  in  the  bowels,  asthmatic 
attacks,  are  the  conditions  which  are  most  often  simulated.  The 
attempt  to  deceive  is  made  not  only  with  reference  to  the  anamnesis, 
but  also  during  the  objective  examination. 

((?)  The  concealment  of  the  appearances  of  disease  is  manifest  with 
reference  to  the  different  sexual  diseases,  especially  syphilis.    Women, 


20  MEDICAL  DIAGNOSIS. 

moreover,  often  attempt  to  avoid  all  statements  in  regard  to  the 
sexual  apparatus,  even  when  it  alone  is  diseased.  Inebriates,  and 
those  who  practise  onanism,  often  confess  their  habits  to  the  physician 
only  with  great  reluctance. 

What  the  Anamnesis  Comprises. 

The  exact  knowledge  of  the  etiology  and  symptomatology  of  internal 
diseases  is  here  the  only  correct  guide,  and,  at  the  same  time,  gives  us 
complete  information  respecting  the  cases  which,  under  various  cir- 
cumstances, come  under  consideration.  We  are  content  with  indi- 
cating the  essential  point  of  view  by  the  introduction  of  a  few 
examples.  We  may  divide  every  anamnesis  into  the  following  two 
parts : 

I.  Previous  history  of  the  patient :  This  comprises  all  that  it  is 
important  to  know  up  to  the  beginning  of  the  disease  on  account  of 
which  the  patient  consults  the  physician. 

II.  The  present  disease :  This  relates  to  the  exciting  causes,  the 
commencement,  and  the  course  to  the  present  time. 

Previous  History  of  the  Patient. 

1.  Hereditary  disease  {heredity).  This  is  of  importance  in  so 
many  diseases  that  in  each  and  every  case  we  have  to  inquire  regard- 
ing the  parents,  brothers  and  sisters  of  the  patient,  and  also  very  often 
regarding  the  brothers,  sisters,  and  parents  of  the  parents.  There 
especially  come  into  view  in  this  connection,  syphilis,  tuberculosis, 
diseases  of  the  brain,  and  certain  general  neuroses.  Heredity,  as 
regards  rheumatism,  carcinoma,  and  diseases  of  the  heart,  is  of  sec- 
ondary importance,  yet  not  immaterial.  These  diseases  are  in  part 
inherited  as  such,  in  part  they  confer  upon  the  descendants  only  the 
organic  foundation,  the  disposition  to  the  new  development  of  the 
same  or  related  diseases.  Different  descendants  are  variously  divided 
by  heredity.  Often  individuals,  or  a  majority,  are  wholly  exempt.  It 
also  happens  that  one  generation  is  entirely  passed  over,  and  the 
trouble  reappears  in  the  following  generation  (hence  the  question 
regarding  the  grandparents). 

Of   the   infectious    diseases,  smallpox    and    syphilis   can,  without 


INTRODUCTION.  21 

doubt,  be  conveyed  in  utero;  but  the  intra-uterine  communication  of 
tuberculosis  from  the  mother  to  the  child  is  extremely  improbable. 

2.  The  manner  of  life,  habits,  profession,  occupation,  residence, 
experiences  as  to  fatigue^  other  harmful  influences  to  which  they  have 
been  exposed,  whether  they  have  descendants,  and,  in  the  case  of 
women,  the  number  and  character  of  their  confinements,  compose  this 
group. 

Under  the  manner  of  life  are  considered  the  diet,  character  of 
dwelling,  and  the  clothing.  Injurious  habits  play  a  very  important 
part  in  the  manner  of  life,  especially  immoderate  use  of  alcohol  and 
tobacco  ;  so,  also,  venereal  excesses  must  be  taken  into  account.  But 
it  is  important  to  remember  that,  at  least  within  certain  limits,  the 
harmful  limit  of  these  things  differs  with  the  individual. 

Profession  and  occupation  on  the  one  hand  affect  the  whole  consti- 
tution, and  on  the  other  are  often  to  be  regarded  as  predisposing  or 
exciting  causes  of  disease ;  finally,  they  may  exert  a  favorable  or  an 
unfavorable  influence  upon  the  course  of  an  existing  chronic  disease. 
Thus,  for  instance,  stonecutters  and  polishers,  by  continually  inhaling 
fine  dust  from  the  stone,  are  very  frequently  inclined  to  bronchial 
attacks  and  diseases  of  the  lungs ;  thus,  too,  the  occupations  that  have 
to  do  with  lead  (type-setting,  type-polishing,  painting),  or  with  mer- 
cury (making  mirrors,  etc.),  frequently  cause  chronic  poisoning  by 
these  metals.  Persons  who  are  engaged  about  sheep,  swine,  horses, 
or  with  the  fresh  skins  and  hair  of  these  animals,  are  apt  to  have 
malignant  pustule  and  other  diseases. 

The  place  of  prior  residence  is  to  be  considered  with  reference  to 
miasmatic  (intermittent),  endemic  diseases,  or  epidemics  which  may 
have  prevailed  there  at  that  time.  With  travellers,  exotic  diseases, 
which  less  frequently  occur  in  their  native  places,  as  lepra,  certain 
exotic  animal  parasites,  etc.,  must  be  thought  of 

As  regards  fatigue,  army  marches  are  to  be  regarded  as  particularly 
fruitful  sources  of  disease ;  so  of  exposure  to  harmful  influences.  A 
fall,  slight,  perhaps,  but  whose  effects  continue ;  or  a  wound,  without 
other  immediate  sequelae  except  that  it  does  not  heal — of  these,  account 
must  be  taken  ;  and  also  of  very  harmful  momentary  experiences,  as 
sorrow,  care,  severe  fright,  anxiety. 

Where  there  is  sterility  we  consider  anomalies  of  the  sexual  apparatus 
of  the  man  or  woman,  but  especially  the  question  of  syphilis.     The 


22  MEDICAL  DIAGNOSIS. 

puerperal  period,  even  when  it  does  not  pursue  an  unfavorable  course, 
may  in  various  ways  be  a  source  of  disease. 

3.  Diseases  which  one  has  had,  not  only  acute  diseases,  but  the 
temporary  outbreak  of  a  chronic  disease  ending  in  apparent  or  real 
recovery. 

Certain  acute  diseases  may  have  as  sequelae  certain  other  diseases 
which  either  are  directly  connected  with  them,  as  paralysis  following 
diphtheria,  nephritis  after  scarlet  fever;  or  which  appear  after  a 
shorter  or  longer  period,  as  valvular  disease  of  the  heart  from  endo- 
carditis in  acute  articular  rheumatism,  arising  during  scarlet  fever. 

The  outbreaks  of  a  chronic  disease  are  often  spoken  of  by  patients 
as  diseases  which  they  have  gone  through  ;  as,  especially,  the  primary 
and  secondary  affections  of  syphilis,  temporary  manifestations  of 
tuberculosis  of  the  lungs,  etc. 

This  point  is  of  special  importance  in  two  ways :  1.  There  are 
certain  acute  diseases  which  one  does  not  easily  have  a  second  time,  as 
scarlet  fever,  measles,  typhoid  fever.  On  the  other  hand,  others 
readily  occur  again,  as  erysipelas,  pneumonia,  articular  rheumatism, 
typhlitis.  2.  Certain  diseases  of  childhood  are '  especially  to  be  con- 
sidered— for  example,  scrofulosis  as  early  indications  of  tuberculosis ; 
manifestations  of  hereditary  syphilis ;  frequent  convulsions  as  an 
early  sign  of  anomalous  condition  of  the  nervous  system.  The  dis- 
eases ordinarily  designated  as  "children's  diseases"  generally  have 
no  significance  as  to  the  future,  but  yet  sometimes,  unfortunately, 
they  leave  lasting  suffering  behind  them,  as  emphysema  after  whooping- 
cough,  etc. 

The  Present  Disease. 

1.  The  possible  exciting  causes  must  be  first  considered.  It  is 
especially  important  for  the  early  diagnosis  of  an  infectious  disease  to 
inquire  whether  the  patient  has  been  exposed  to  infection.  Many 
diseases  are  conveyed  by  a  very  short  exposure,  others  require  a 
longer,  or  even  a  personal  contact.  Also  the  period  of  incubation 
must  be  considered.  This  is  the  period  from  the  moment  of  infection 
until  the  outbreak  of  the  disease.  With  most  transferable  diseases 
this  period  is  of  a  known,  somewhat  exactly  defined  duration.  More- 
over, "taking  cold,"  over-exertion,  improper  eating  and  drinking, 
taking  of  poison,  etc.,  come  under  consideration. 


INTRODUCTION.  23 

It  is  to  be  remarked  that  the  laity  often  assume  something  as  an 
exciting  cause,  thus  especially  "taking  cold." 

2.  The  first  appearances  and  the  course  of  the  disease  up  to  the 
time  of  examination. 

With  chronic  diseases  the  first  appearances  are  sometimes  at  the 
beginning  scarcely  noticeable :  they  often  consist  only  in  a  change 
from  the  previous  behavior,  unless  the  new  condition  in  itself  directly 
appears  to  be  one  of  disease ;  a  person  who  previously  had  red  cheeks 
becomes  paler  (all  kinds  of  wasting  diseases),  a  stout  person  without 
other  reason  becomes  thin,  one  who  always  previously  ate  and  drank 
little,  all  at  once  eats  and  drinks  considerably  (diabetes),  a  person 
formerly  very  orderly  becomes  disorderly,  forgetful  (disease  of  the 
brain,  especially  progressive  paralysis).  Even  when  they  have  made 
considerable  progress,  such  gradually  developing  disturbances  often 
are  not  at  all  noticed  by  ignorant  and  indiflferent  people. 


CHAPTER  II. 

EXAMINATION  OF  PATIENTS. 

The  examination  of  the  patient  comprises  : 

1.  A  general  examination,  which  takes  into  account  certain  phe- 
nomena of  disease  which  concern  the  organism  as  a  whole,  and  are  the 
expression  of  a  pathological  change  of  the  whole  organism. 

2.  A  special  examination,  which  inquires  into  the  different  regions 
and  organs,  the  secretions  and  excretions  of  the  body.  At  the  bed- 
side we  generally  proceed  in  such  a  way  that,  beginning  at  the  head, 
we  gradually  go  downward,  in  order  to  facilitate  the  investigation  by 
examining  contiguous  organs.  But  in  many  cases  it  is  better  to  group 
together  organs  that  are  functionally  related,  no  matter  what  their 
anatomical  location  may  be,  since  we  thus  quickly  obtain  a  compre- 
hensive view  of  the  way  in  which  the  affected  organs  or  systems  are 
disturbed.  Thus,  in  diseases  of  the  heart,  the  heart  and  bloodvessels, 
in  diseases  of  the  nervous  system,  the  central  and  peripheral  nervous 
systems  are  examined  together.  Sometimes,  as  in  the  case  of  very 
weak  or  very  unruly  patients,  as  children,  the  examination  of  the 
body  must  be  very  brief.  Here  the  expertness  of  the  physician  espe- 
cially is  put  to  the  test  to  the  utmost  degree. 

It  will  best  answer  the  purposes  of  study  if  the  division  of  the 
subject  throughout  strictly  conforms  to  the  organ-systems,  and  hence 
the  special  part  is  divided  into  : 

I.  Examination  of  the  respiratory  apparatus. 
II.  Examination  of  the  circulatory  apparatus. 
III.  Examination  of  the  digestive  apparatus. 
IV.  Examination  of  the  urinary  apparatus,  including  also  in  part 

the  sexual  apparatus. 
V.  Examination  of  the  nervous  system. 

[note  by  the  translator  upon  keeping  records  of  cases,  and  a 
form  for  recording  the  results  of  a  medical  examination. 

It  is  not  practicable  at  the  bedside  to  go  through  any  set  form  for 
conducting  the  inquiry  regarding  the  present  illness.     The  most  direct 
(24) 


EXAMINATION  OF  PATIENTS.  25 

way  of  getting  at  it,  and  the  one  that  will  lead  to  the  most  satis- 
factory replies  to  our  interrogatories,  is  to  ask  the  question,  What  is 
your  complaint  ?  How  are  you  sick  ?  or  some  such  direct  question 
as  this.  In  this  way  we  get  at  once  at  the  disease  we  are  called  upon 
first  to  diagnose  and  then  to  treat.  As  we  proceed  we  will  arrange 
the  facts  in  our  minds,  and  when  we  make  the  record,  we  shall  place 
them  in  a  natural  and  logical  order.  Having  a  regular  form  for 
keeping  records  of  cases  soon  develops  an  order  of  procedure  in 
accordance  with  it. 

Case-taking  is  a  most  valuable  aid  to  the  student  in  clinical  study. 

1.  He  learns  to  make  a  systematic  examination  of  the  patients  he 
sees.  He  forms  the  habit  of  bringing  before  his  mind  each  factor  in 
the  case  in  orderly  succession.  There  are  two  advantages  from  this. 
First.  He  forms  the  habit  of  thoroughness  in  examining  his  cases. 
Second.  He  can  readily  compare  one  case  with  another — having 
arranged  the  factors  of  each  in  like  order.  While  it  is  not  necessary 
in  making  the  examination  to  have  or  to  follow  strictly  a  printed 
form,  yet  it  is  desirable  to  have  some  regular  form  for  making  the 
record,  so  that  cases  that  are  similar  can  be  readily  compared.  One 
case  may  require  going  over  only  a  few  points,  in  another  it  will  be 
necessary  to  examine  every  organ  in  the  body. 

2.  The  memory  is  greatly  strengthened.  Memory  depends  upon 
attention  and  repetition.  Case- taking  cultivates  both  of  these  in  an 
eminent  degree.  Facts  and  symptoms  that  else  would  escape  notice 
entirely,  or  be  only  slightly  noted,  are  brought  prominently  before  the 
mind  for  consideration.  Their  value  or  bearing  is  weighed,  and  so 
they  are  strongly  impressed  upon  the  mind. 

3.  The  mind  is  developed  by  this  habit  of  carefully  reflecting  upon 
every  feature  of  a  case.  Thought  is  both  stimulated  and  made  easy. 
Clearness  and  power  of  thought  are  increased.  Independence  of 
judgment  is  cultivated.  Both  knowledge  and  intellectual  cultivation 
are  acquired.  "  By  knowledge  is  understood  the  mere  possession  of 
truths ;  5y  intellectual  cultivation,  or  intellectual  development,  the 
power,  acquired  hy  exercise  of  the  higher  faculties,  of  a  more  varied, 
vigorous  and  protracted  activity.''  (Sir  William  Hamilton.) 

4.  Ease  and  habit  of  writing  are  almost  unconsciously  acquired. 
This  is  most  valuable.  The  great  majority  of  physicians  keep  no 
records  of  cases.     Many  never   record  or   publish  important  ones, 


26  MEDICAL  DIAGNOSIS. 

because  they  have  not  the  facility  of  -writing  which  comes  with  prac- 
tice. Anything  is  easy  to  the  2^fCLcti^^d  hand.  "  Who  can  estimate 
how  much  we  have  lost,  from  the  fact  that  generations  of  men  gifted 
with  powers  of  acute  and  shrewd  observation,  have  passed  away 
without  leaving  one  record  behind  them  ?  Think  not  that  it  is  the 
hospital  physician  or  surgeon  alone  who  can  advance  the  progress  of 
medicine.  There  is  not  a  practitioner  who  could  not  aid  this  great 
work.  But  he  can  only  add  to  it  with  efficiency  if  he  has  faithfully 
recorded  his  observations.,  and  does  not  trust  to  the  general  and  vague 
impressions  of  unassisted  memory.  Therefore,  on  all  grounds,  per- 
sonal to  yourselves  and  general  for  medical  science,  so  engrain  this 
habit  within  you  that  it  becomes  a  second  nature."  (Coupland.) 

The  Anamnesis. 

Personal  and  Previous  History. 

Name,  Address, 

Birthplace,  ^ge>  Sex, 

Family  history — Heredity  : 

Father, 

Mother, 

Brothers, 

Sisters, 

Other  relatives. 
Manner  of  life,  habits,  occupation,  residence,  etc.. 
Previous  diseases — character  and  results. 

(Note  each  one  that  was  of  such  a  character  as  to  have  any  lasting 
eflfect  upon  the  health  or  vitality.) 

Present  Illness. 
Duration, 

Possible  exciting  cause. 

How  began — suddenly  or  not ;  prodromal  symptoms, 
Course  of  the  disease  till  the  time  of  examination. 


EXAMINATION  OF  PATIENTS.  27 

Examination  of  the  Patient. 

General  examination : 
Appearance, 
Psychical  condition, 
Position  in  bed, 
Structure  and  nutrition. 
Skin  and  subcutaneous  tissues, 
Temperature, 
Pulse. 

This  covers  the  general  features  of  every  case.  Attention  has  been 
directed,  by  what  has  been  learned  thus  far,  to  some  one  or  more  of 
the  special  organs  or  systems  of  the  body.  It  is  usually  best  first  to 
examine  that,  and  to  make  this  examination  very  full  and  thorough. 
Then  the  remaining  organs  of  the  body  can  be  examined  with  greater 
or  less  fulness,  according  as  they  are  found  to  be  aifected  by  the 
principal  disease,  or  as  they  are  related  to  the  one  specially  diseased. 
It  is  well  to  form  the  habit  of  following  a  certain  order  in  examining 
each  organ.  One  is  much  less  apt  to  overlook  any  part ;  and,  too, 
as  has  already  been  pointed  out,  the  records  will  be  more  easily  con- 
sulted and  compared.  For  this  purpose,  it  is  well  to  take  the  order  of 
the  text-book,  so  as  to  become  thoroughly  familiar  with  each  subject. 
It  is  not  of  so  much  importance  that  this  or  that  one  is  adopted,  pro- 
vided it  is  a  good  one.  But  we  have  here  a  notable  illustration  of  the 
truth  and  value  of  the  Spanish  proverb:  "  Beware  of  the  man  of  one 
book." 

Presuming  that  those  who  use  this  work  will  follow  the  order  laid 
down  in  it,  the  form  now  given  conforms  with  the  order  in  which  the 
systems  are  treated. 

Special  Examination. 

Examination  of  the  respiratory  apparatus : 
Nose, 
Mouth, 
Larynx. 


28  MEDICAL  DIAGNOSIS. 

Examination  of  the  lungs : 

Inspection  of  thorax, 

Palpation  of  thorax, 

Percussion  of  thorax, 

Auscultation  of  lungs, 

Auscultation  of  voice, 

Measurement  of  thorax, 

Cough  and  expectoration. 
Examination  of  circulatory  apparatus: 

Inspection  and  palpation  of  the  region  of  the  heart, 

Percussion  of  the  heart,  Apex-beat, 

Auscultation  of  heart, 

Examination  of  the  arteries  and  veins, 

Examination  of  the  blood. 
Examination  of  the  digestive  apparatus : 

Mouth,  gums,  and  pharynx. 

Stomach, 

Intestines, 

Peritoneum, 

Liver, 

Spleen, 

Pancreas, 

Contents  of  the  stomach  and  vomited  matters, 

Feces. 
Examination  of  the  urinary  apparatus : 

Kidneys, 

Ureters  and  bladder. 
Examination  of  the  urine: 

Amount  in  twenty-four  hours, 

Reaction,  Odor, 

Specific  gravity, 

Sediment, 

Albumin, 

Blood, 

Bile, 

Sugar, 

Other  constituents. 


EXAMINATION  OF  PATIENTS.  29 


Examination  of  the  nervous  system : 
Disturbances  of  sensibility, 
Location  of, 
Superficial  or  deep, 
Motor  disturbances, 
Disturbances  of  speech, 
Condition  of  the  organs  of  special  sense. 


PART  II. 


CHAPTER    III. 

GENERAL  EXAMINATION. 

This  consists  of  a  number  of  subordinate  divisions,  namely:  we 
have  to  consider : 

I.  The  psychical  condition  of  the  patient. 
II.  The  position  in  bed. 

III.  The  general  structure  of  the  body  and  the  nutrition. 

IV.  The  skin  and  the  subcutaneous  cellular  tissue. 
V.  The  temperature  and  the  pulse. 

I.  The  Psychical  Condition  of  the  Patient. 

From  this — that  is,  from  the  clearness  of  his  intelligence,  his  sus- 
ceptibility to  external  impressions,  his  power  of  thought,  from  the 
possible  presence  of  depression  or  irritability — we  may  often  obtain 
important  points  of  diagnosis  ;  both  for  diagnosis  in  the  narrower 
sense,  certain  diseases  being  accompanied  with  definite  manifestations 
of  this  kind,  and  for  diagnosis  in  a  broader  sense,  since  the  severity 
of  a  disease,  the  possible  turn  for  better  or  worse,  often  becomes 
manifest  by  the  psychical  condition  of  the  patient.  (Regarding  this 
and  the  way  in  which  the  examination  in  this  direction  is  conducted, 
see  the  section  on  "  Examination  of  the  Nervous  System.") 

II.  The  Position  of  the  Patient. 

This  furnishes  a  very  simple  aid  to  diagnosis,  because  generally  it 
can  be  determined  by  a  single  glance  of  the  eye.  From  it  conclusions 
in  various  directions  may  be  drawn.  People  in  health  or  only  slightly 
sick  usually  assume  the  dorsal  position,  or  a  position  upon  one  side, 

(31) 


g2  MEDICAL  DIAGNOSIS. 

in  a  certain  unconstrained  comfortable  position  (the  active  dorsal  or 
side  position).  On  the  contrary,  patients  who  either  are  not  wholly 
conscious,  or  who  have  become  very  weak,  frequently  are  inclined  to 
slide  down  toward  the  foot  of  the  bed  and  sink  into  a  heap  there,  a 
position  which  manifests  weakness,  and  iii  some  respects,  but  espe- 
cially for  breathing,  is  very  unfavorable  (the  passive  dorsal  and  side 
position). 

In  acute  infectious  diseases,  more  than  elsewhere,  the  passive  dorsal 
position  is  specially  noteworthy.  It  is  particularly  ^o  when  apathy 
and  clouded  intelligence  are  combined  with  great  muscular  weakness, 
as  is  frequently  the  case  in  typhoid  fever,  where  such  a  condition  of 
the  patient  is  so  frequently  and  sometimes  early  present  that  it  may 
aid  in  the  diagnosis. 

But  in  still  another  way  the  position  in  bed  is  sometimes  charac- 
teristic. Patients  with  acute  affections  of  the  chest  organs  involving 
only  one  side  (pneumonia,  pleurisy,  pneumothorax)  generally  lie  upon 
the  side,  and  for  the  most  part  upon  the  side  affected.  This  may  be 
due  to  various  causes.  The  pain  caused  by  breathing  is  generally  in 
this  way  diminished,  because  by  lying  upon  the  side  the  motion  of 
that  side  is  very  much  lessened,  while,  on  the  other  hand,  the  motion 
of  the  opposite  side  in  breathing  is  greater  than  when  the  patient 
lies  upon  the  back  ;  hence  the  sound  side,  when  the  patient  lies  upon 
the  diseased  side,  can  better  compensate  for  the  loss  of  the  portion 
diseased.  In  exudative  pleuritis  frequently  there  is  the  further 
advantage  in  lying  upon  the  affected  side  that  the  exudation  least 
interferes  by  pressure  with  the  healthy  side.' 

Yet  patients  with  pneumonia  not  infrequently  lie  upon  the  healthy 
side,  because  they  have  least  pain  in  this  position.  That  in  diseases 
of  the  chest  in  general  patients  are  inclined  at  the  beginning  of  the 
disease  to  lie  upon  the  sound  side,  and  later  upon  the  diseased  side, 
I  am  not  able  to  affirm. 

Difficult  breathing,  dyspnoea,  if  extreme,  prompts  one  to  assume 
the  upright  sitting  posture  in  bed  or  in  an  easy  chair — orthopnoea  ; 
because  in  this  attitude  the  action  of  the  accessory  muscles  of  respira- 
tion is  more  effective  than  when  lying  down.  Orthopnoea  may,  there- 
fore, occur  with  all  diseases  which  are  accompanied  with  marked 
interference  with  respiration  :  as  in  narrowing  of  the  air-passages  in 
disease  of  the  lungs  (comparatively  rare  with  phthisis — see  under 


GENERAL  EXAMINATION.  33 

"Dyspnoea"),  in  diseases  of  the  pleura,  heart,  pericardium,  with  large 
effusions  into  the  abdominal  cavity,  which  press  the  diaphragm  up ; 
and  in  general  dropsy  with  effusions  into  the  cavities  of  the  body. 
In  the  severest  cases  the  patients  may  indeed  be  obliged  to  keep 
the  sitting  posture,  even  to  sleep.  The  continued  exertion  of  sitting 
and  the  diminished  sleep  obtained  in  this  position,  besides  the  great 
anxiety  and  excitement  these  patients  generally  have,  usually  quickly 
bring  on  exhaustion. 

Another  group  of  characteristic  situations  and  positions  in  bed  refer 
to  diseases  of  the  brain  and  its  membranes.  Thus  meningitis  betrays 
itself  often  at  the  first  glance  by  opisthotonus,  with  the  head  boring 
into  the  pillow,  so-called  contraction  of  the  neck ;  in  circumscribed 
disease  of  the  cerebrum  the  head  is  sometimes  persistently  inclined  to 
be  drawn  forcibly  to  one  side :  forcible  contraction  of  the  head ;  in 
affections  of  the  cerebellum,  also  of  the  crus  cerebelli,  we  not  infre- 
quently see  the  whole  body  continually,  as  one  lies  in  bed,  drawn, 
sharply  to  one  side,  and,  when  turned  over  to  the  dorsal  position, 
returning  immediately  again  to  this  constrained  position.  These 
phenomena,  however,  are  in  part  to  be  reckoned  as  convulsive  con- 
ditions, which  indeed  bring  about  the  greatest  variety  of  characteristic 
positions  and  attitudes  of  the  body.  These  latter,  however,  are  gener- 
ally quite  transitory. 

III.  The  Structure  of  the  Body  and  Nutrition. 

The  development  of  the  skeleton  determines  the  form  of  the  body. 
Generally  firm  bones  and  broad,  flat  chest  are  characteristic  of  strong 
and  enduring  health :  while  those  persons  of  delicate  skeleton,  espe- 
cially with  slender  ribs  and  narrow  chest,  are  considered  capable  of 
both  limited  life  and  endurance.  Yet  this  is  only  a  general  rule. 
We  often  see  people  of  delicate  build  who  are  remarkably  tough  and 
enduring,  both  with  reference  to  exertion  and  disease ;  and  not  infre- 
quently we  find  robust  people  with  little  power  of  resistance,  especially 
to  acute  diseases. 

Unusually  small  development  of  the  skeleton  is  often  observed  in 
idiots  and  cretins  ;  and,  in  more  rare  cases,  in  dwarfs,  without  any 
other  anomaly. 

The  form  of  the  thorax  is  of  especial  importance.     With  a  slight 

3 


34  MEDICAL  DIAGNOSIS. 

and  narrow  chest-cavity  there  is  a  proportionally  frequent  disposition 
to  tuberculosis  of  the  lungs ;  and,  on  the  other  hand,  a  certain  fulness 
carries  with  it  a  tendency  to  emphysema  of  the  lungs.  This  will  be 
more  particularly  spoken  of  under  Respiratory  Organs. 

The  significance  of  the  structure  of  the  pelvis  is  manifest  in  the 
practice  of  obstetrics. 

The  muscles,  the  subcutaneous  tissues,  and  the  skin  furnish  a 
means  of  judging  of  the  nutrition,  and  also  of  the  weight.  In  general, 
well-nourished  and  healthy  persons  have  a  certain  volume  and  firm- 
ness of  muscles.  There  is  also  a  relation  between  the  muscles  and 
the  skeleton.  But  even  in  perfectly  normal  persons  there  is  a  very 
marked  difference  in  the  volume  of  the  muscles,  which  is  not  always 
explained  by  differences  of  occupation.  By  experience  the  eye  grad- 
ually becomes  quick  in  recognizing  a  suspiciously  small  muscular 
volume ;  yet  the  firmness  of  the  muscles'  is  a  better  guide  to  an 
opinion  than  their  volume. 

The  fat  of  the  subcutaneous  tissues  may  be  very  differently  de- 
veloped in  persons  of  good  health.  As  a  rule,  it  varies  with  the  age, 
being  greater  for  the  first  years  of  life  up  to  the  forty-fifth  or  fiftieth 
year.  Beyond  this  it  again,  as  a  rule,  becomes  less.  It  also  some- 
times varies  in  a  shorter  time  without  being  caused  by  disease,  as  in 
women  at  about  twenty  years  of  age.  It  varies  also,  as  a  matter 
of  course,  with  the  kind  and  the  richness  of  food,  as  well  as  with 
the  occupation.  Loose  adipose  tissue  generally  indicates  a  weak 
organization. 

A  marked  degree  of  leanness  of  the  subcutaneous  tissue  is,  under 
all  circumstances,  suspicious,  and  suggests  an  examination  as  to 
whether  it  may  be  caused  by  disease.  In  the  same  way  the  accumu- 
lation of  fat  beyond  a  certain  degree  becomes  pathological.  The 
measure  or  degree  can  only  be  established  by  experience. 

Of  much  greater  importance  is  a  commencing,  even  though  a  slight, 
wasting  away  of  the  subcutaneous  fat,  and  eventually  also  of  the  mus- 
cles. As  we  have  said,  this  is  sometimes  physiological.  It  can  also 
take  place,  as  among  the  poorer  classes,  from  very  poor  nourishment. 
But  in  the  majority  of  cases  it  is  caused  by  disease,  and  it  is,  there- 
fore, important  not  to  overlook  it.  This  wasting  can  only  really  be 
learned  by  the  physician  when  he  has  known  the  patient  for  some 
time.     When  this  is  not  the  case  he  must  rely  upon  the  statements  of 


GENERAL  EXAMINATIOX.  35 

the  patient  and  his  surroundings,  and,  therefore,  this  subject  properly 
belongs  to  the  "  previous  history."  When  the  emaciation  is  marked, 
its  proof  is  furnished  by  the  condition  of  the  skin.  In  these  cases  the 
skin  of  the  patient's  whole  body  is  loose,  and  can  easily  be  taken  up 
in  folds. 

Excessive  wasting  is  denominated  ati'ophy,  emaciation  ;  and  when 
this  is  accompanied  by  general  loss  of  strength  and  failure  of  function, 
marasmus  or  cachexia.. 

The  weight  of  the  body  is  an  excellent  index  and  one  which  is 
superior  to  all  other  signs  of  corpulence,  and  its  increase  or  diminu- 
tion. The  absolute  value  of  the  weight  of  the  body  in  the  different 
periods  of  life  has  no  diagnostic  imprest,  for  the  reason  that  it  varies 
within  wide  hmits.  Likewise  the  relation  of  the  weight  of  the  body 
to  the  height  and  the  circumference  of  the  chest  has  scarcely  any 
significance  for  our  purposes.  On  the  other  hand,  change  in  the 
body-weight  wrought  by  disease  is  of  the  greatest  importance.  In 
chronic  diseases  this  is  an  extremelv  valuable  means  of  determining 
whether  the  disease  is  increasing,  standing  still,  or  is  being  recovered 
from.  Taking  the  weight  regularly  .(say,  weekly)  in  cases  of  tubercu- 
losis is  especially  to  be  recommended,  also  in  diseases  of  the  digestive 
apparatus.  In  convalescence  from  acute  diseases,  following  the  weight 
of  the  body  is  also  a  very  important  aid,  especially  for  the  early  recog- 
nition of  the  possibility  of  the  disease  becoming  chronic,  or  of  the 
presence  of  associated  chronic  diseases.  Moreover,  in  all  these  cases 
we  must  remember  that  oedema  (which  see)  produces  a  deceptive 
increase  in  the  weight  of  the  body. 

According  to  Bernhardt  (cited  by  H.  Vierordt),  the  relation  of  the 
weight  of  the'body,  P,  to  the  height,  H  (in  cm.),  and  to  the  average 
circumference  of  the  chest,  C  (measured  at  the  level  of  the  nipples, 
in  cm.),  for  the  average  individual,  may  be  reckoned  as  follows : 


i'=(i)k'i 


^  ;  kilograms. 


The  weight  of  the  body  of  the  newly-born  and  its  increase  during 
the  first  months  is  of  special  significance.  Regarding  this  subject, 
see  works  upon  obstetrics  and  diseases  of  children,  also  Daten  und 
Tabellen,  by  H.  Vierordt. 

Diseases  of  the  alimentary  tract,  more  than  others,  produce  emacia- 


3g  MEDICAL  DIAGNOSIS.  ♦ 

tion ;  next,  all  febrile  diseases,  whether  acute  or  chronic  (of  the  latter 
especially  tuberculosis),  then  severe  forms  of  diabetes  mellitus,  and, 
finally,  all  malignant  growths.  A  certain  degree  of  emaciation  can 
be  produced  by  any  disease  of  an  internal  organ. 

IV.  Skin  and  Subcutaneous  Cellular  Tissue. 

In  medical  diagnosis  the  condition  of  the  skin  and  subcutaneous 
tissue  is  considered  with  reference  to  the  following  points : 

A.  The  condition  of  general  nutrition. 

B.  The  moisture  of  the  skin ;  perspiration. 

C.  The  color  of  the  skin. 

D.  Certain  pathological  appearances  of  general  diagnostic  value 
(characteristic  eruptions,  hemorrhages,  scars,  etc.). 

E.  The  presence  of  oedema. 

F.  Possible  emphysema  of  the  skin. 

Skin  diseases  proper  and  certain  acute  infectious  diseases,  with 
special  localization  upon  the  skin  (the  co-called  acute  exanthematous 
diseases)  are  not  considered  in  this  work. 

A.     THE    STATE    OF    NUTRITION    OP    THE    SKIN. 

In  old  age  the  nutrition  of  the  skin  is  diminished  over  the  whole 
body.  This  is  physiological.  In  earlier  years  a  noticeable  general 
atrophy  of  the  skin  exists  only  where  there  is  a  very  severe  cachexia. 
The  skin  is  then  thin  and  generally  dry.  It  loses  its  tone,  and  when 
taken  up  in  a  fold  resumes  its  place  slowly. 

The  different  forms  of  circumscribed  atrophy  of  the  skin  which 
have  been  described  do  not  interest  us  here.  They  belong  to  works 
upon  skin  diseases. 

B.    THE   MOISTURE    OF   THE    SKIN  ;    PERSPIRATION. 

Physiology  teaches  us  that  the  moisture  of  the  skin,  as  well  as  the 
visible  secretion  of  perspiration,  is  influenced  by  various  circumstances. 
It  is  increased  during  active  exertion,  by  increased  temperature  of  the 
blood,  by  moist  heat,  by  mental  impressions,  especially  fear;  finally, 
by  certain  ingesta,  as  hot  tea,  by  pilocarpine,  etc. 


GENERAL  EXAMINATION.  37 

In  some  of  these  cases  there  is  at  the  same  time  an  increase  of  heat 
of  the  body,  which  is  overcome  by  the  perspiration,  cooling  being 
caused  by  its  evaporation. 

Perspiration  is  a  regulator  of  the  temperature  of  the  body. 

The  loss  of  water  by  evaporation  (the  greater  part  of  the  insensible 
perspiration)  in  health  is,  cceteris  'paribus,  greater  at  night  than  during 
the  day.     It  seems  to  alternate  with  the  secretion  of  the  urine. 

In  healthy  people  the  secretion  of  perspiration  is  in  this  way  very 
changeable.  But  it  is  still  more  so  in  cases  of  illness.  It  may  be 
increased  to  such  a  degree  that  the  whole  bed  may  be  wet  through 
(hyperidrosis).  On  the  other  hand,  it  may  be  so  diminished  (hyphi- 
drosis)  that  the  skin  is  perfectly  dry  (anidrosis).  Hyperidrosis  of  the 
whole  body  is  called  hyperidrosis  universalis  ;  if  confined  to  a  part  of 
the  body,  hyperidrosis  localis.  The  latter  may  be  unilateral  (hemi- 
drosis). 

A  general  perspiration  may  take  place  in  cases  of  illness : 

1.  When  there  are  present  conditions  which  are  analogous  to  those 
which  produce  it  in  persons  in  a  state  of  health,  as  in  cases  of  strong 
tetanic  convulsions  by  the  increased  muscular  work  and  heart-action. 
On  the  contrary,  in  cases  of  epileptic,  hysterical,  and  other  convul- 
sions we  have  either  no  perspiration  or  at  least  none  corresponding 
with  the  very  great  muscular  exertion ;  in  all  possible  diseased  con- 
ditions connected  with  great  excitement,  especially  fear,  or  with  severe 
pain ;  and  again,  sometimes  (not  always,  see  below  under  Anidrosis) 
from  a  high  degree  of  atmospheric  heat,  warm  baths,  moist  warm 
pack,  or  sudorifics  (pilocarpine,  etc.).  Morphine,  also,  with  some 
persons,  induces  perspiration. 

2.  In  difficult  breathing — dyspnoea.  This  is  generally  connected 
with  sweating.  (In  the  same  way  sweating  sometimes  occurs  with 
heart  disease,  accompanied  by  an  engorged  condition  of  the  "  greater" 
circulation  ;  also  with  all  diseases  of  the  respiratory  organs  and  their 
surroundings,  which  interfere  with  respiration.) 

3.  In  febrile  diseases.  Sweating  usually  occurs  with  the  fall  of  the 
temperature  in  these  diseases.  The  most  important  instances  are  (a)  the 
critical  sweat  of  a  rapid  definite  decline  of  the  fever  especially  frequent 
in  pneumonia  and  febris  recurrens  [relapsing  fever] ;  (b)  the  sweat 
which  regularly  accompanies  the  fall  of  temperature  in  intermittent 
fever  and  pyaemia  (diseases  which  manifest  themselves  by  rapid  rise 


38  MEDICAL  DIAGNOSIS. 

and  fall  of  temperature),  the  night-sweats  of  the  hectic  fever  of 
phthisis  and  the  sweat  of  the  remittent  (hectic)  fever  of  typhoid 
fever  ;  and  (c)  the  cold  sweat  of  collapse  (that  is,  the  sudden  failure  of 
strength  in  the  death  struggle). 

Acute  articular  rheumatism  manifests  itself  by  considerable  perspi- 
ration, which  may  not  depend  upon  a  fall  of  temperature.  Finally, 
there  is  always  the  inclination  to  perspiration  in  the  commencement 
of  convalescence  from  severe  diseases  and  in  parturient  patients,  when 
there  is  great  weakness  and  the  heart  is  easily  excited. 

Local  sweating  occurs  in  various  neuroses,  also  in  organic  diseases 
of  the  nervous  system.  There  is  very  frequently  sweating  of  the 
whole  of  one  side  (hemidrosis),  or  of  the  head  alone,  as  in  Basedow's 
disease,  migraine,  hysteria ;  localized  disease  of  the  brain,  and  in 
mental  diseases. 

Diminished  secretion  of  stveat,  even  to  complete  anidrosis,  is  ob- 
served chiefly  in  high  continued  fever.  It  is,  moreover,  a  peculiarity 
of  all  diseases  which  are  accompanied  with  considerable  loss  of  Avater 
by  the  bowels  or  the  kidneys,  of  severe  diarrhoea  of  any  kind,  con- 
tracted kidney,  and  diabetes.  The  anidrosis  which  exists  with  general 
dropsy,  in  consequence  of  the  anaemia  of  the  skin  produced  by  the 
pressure  and  stretching,  has  a  peculiar  appearance. 

The  anidrosis  of  high  fever  and  general  dropsy  is  very  persistent, 
often  resisting  all  therapeutic  measures,  both  those  acting  directly 
upon  the  skin  (moist  heat,  etc.)  and  the  medicines  already  mentioned. 

Qualitative  alterations  of  sweat  exist  sometimes  in  severe  jaundice, 
when  it  contains  the  coloring-matter  of  bile  and  is  yellow  in  color ; 
also,  when  the  urinary  secretion  is  greatly  diminished  or  entirely  sup- 
pressed, as  in  nephritis,  diseases  of  the  urinary  tract,  and  cholera.  It 
then  contains  considerable  quantities  of  urinary  products,  which,  by 
the  evaporation  of  the  perspiration,  crystallize  upon  the  skin  (espe- 
cially upon  the  nose  and  forehead)  in  small  white  scales.  This  is 
called  uridrosis,  the  scales  giving  the  reaction  of  urinary  ingredients. 

C.    THE    COLOR    OF    THE    SKIN. 

As  is  well  known,  races  differ  in  the  color  of  the  skin,  but  even  in 
the  Indo-Germanic  race  there  are  variations  depending  upon  the 
stock,  the  climate  (blonde,  brunette).     In  some  nations  the  pale,  in 


GENERAL  EXAMINATION.  39 

others  a  more  florid,  complexion,  especially  of  the  face,  prepon- 
derates. We  know  that  there  are  differences  depending  on  the  mode 
of  life;  also  that,  even  as  regards  the  so-called  healthy  color  of  skin, 
considerable  individual  variations  exist.  But,  after  all,  the  hue  of  the 
skin  stands  in  intimate  relation  to  a  large  number  of  diseases  of  in- 
ternal organs.  It  is  considered  most  suitable  to  judge  from  the  color 
of  the  countenance,  the  portion  of  the  skin  most  generally  reddened  ; 
and,  since  on  every  hand  we  have  opportunity  for  practice,  it  is  well 
to  sharpen  the  eye  for  critically  examining  this  part  of  the  body. 
But  the  color  of  the  countenance  can  sometimes  deceive  us  (vide 
especially  under  "red  skin  "),  and  it  is  therefore  advisable  always  to 
examine  the  mucous  membrane  of  the  lips,  mouth,  and  throat,^  and, 
besides,  to  glance  at  the  color  of  the  skin  of  a  part  of  the  body  usually 
covered  by  the  clothing. 

We  recognize  the  following  abnormal  colorations  of  the  skin  : 

1.  A  pale  skin. 

2.  The  abnormally  red  skin. 

3.  The  blue-red  cyanotic  skin. 

4.  The  yellow  skin  of  icterus. 

5.  The  bronze  skin. 

6.  The  gray  skin  produced  by  nitrate  of  silver. 

1.    The  Pale  Skin. 

This  can  to  a  certain  extent  be  physiological,  especially  in  persons 
who  spend  little  time  in  the  open  air.  In  these  cases  a  glance  at  the 
mucous  membrane  gives  further  information.  But  one  can  be  de- 
ceived regarding  such  persons,  who,  having  exposed  the  face  (also 
arms  and  hands)  frequently  to  radiant  heat,  or  to  cold  and  heat  in 
rapid  succession,  often  have  a  local  redness  of  face.  This  redness  of 
face  may  arise  from  other  causes  (p.  41). 

Only  experience  can  enable  one  to  distinguish  between  physiological 
paleness  and  that  produced  by  disease.  The  recognition  of  the  latter 
is  frequently  aided  in  that  it  is  associated  with  a  grayish,  yellowish 
color  (see  below).     The  color  of  the  skin  is  produced  by  the  fulness 

1  The  conjunctival  mucous  membrane  is  not  included.  It  is  not  decisive,  since  many 
persons  in  whom  the  teguments  are  elsewhere  pale,  at  times  have  the  conjunctiva 
easily  injected. 


40  MEDICAL  DIAGNOSIS. 

of  its  capillary  vessels.  The  abnormal  paleness  may  be  dependent 
upon  disturbance  of  the  circulation  (and  in  consequence  of  diminished 
force  of  the  heart  or  active  narrowing  of  the  peripheral  arteries), 
or  by  a  lessening  of  the  quantity  of  the  blood  constituents,  chiefly 
of  the  haemoglobin.  We  distinguish  :  {a)  Temporary  paleness,  which 
is  partly  physiological  and  partly  pathological.  It  occurs  with  strong 
emotion,  especially  fright;  in  syncope  or  fainting;  in  the  chill  of 
fever,  which  ordinarily  accompanies  a  rapid,  considerable  elevation  of 
temperature ;  and  in  spasm  of  the  capillary  vessels,  (h)  Paleness 
lasting  a  longer  or  shorter  time.  This  comes  on  sometimes  quite 
rapidly,  at  least  in  the  course  of  a  few  moments,  during  profase 
hemorrhage  and  in  sudden  collapse — that  is  to  say,  in  sudden  failure 
of  the  heart  as  it  occurs  in  acute,  and  sometimes  chronic,  diseases, 
and  in  acute  poisoning.  It  is  accompanied  by  a  rapid  and  small 
pulse,  increasing  weakness,  and,  finally,  loss  of  consciousness.  Where 
there  is  external  hemorrhage  the  condition  is  perfectly  plain.  But 
cases  of  seve^^e  internal  hemorrhage,  especially  of  the  stomach  or 
bowels,  of  ruptured  aneurism,  hemorrhage  from  internal  wounds  of 
any  kind,  are  declared  only  by  this  sudden  paleness,  sometimes  even 
befoi'e  the  patients  themselves,  if  quiet  in  bed,  complain  of  weakness. 

In  a  case  of  endocarditis  which  I  saw,  the  patient  became  pale,  as 
one  does  from  an  internal  hemorrhage,  with  increased  frequency  of 
pulse  and  stupor,  within  less  than  ten  minutes.  At  the  autopsy  there 
was  found  a  recent  total  rupture  of  an  aortic  valve. 

This  paleness  can  develop  more  slowly,  within  a  few  hours  or  days, 
by  considerable  repeated  hemorrhages  ;  as  a  symptom  of  weakening 
of  the  heart's  activity  in  all  acute  and  chronic  diseases  of  the  heart 
and  pericardium  ;  also  in  diseases  of  parts  adjacent  to  the  heart,  as 
pleurisy  and  abdominal  affections,  Avith  much  pressure  upon  the  dia- 
phragm, in  case  they  interfere  with  the  action  of  the  heart ;  finally,  in 
many  acute  diseases,  especially  in  diphtheria,  in  heart-failure  from 
diseases  affecting  the  muscular  structure  of  the  heart ;  and  very  often, 
and  in  a  very  striking  way,  in  acute  catarrh  of  the  stomach  (acute 
dyspepsia). 

Finally,  paleness  of  the  skin  comes  on  in  certain  conditions  gener- 
ally unnoticeable,  insidious,  and  is  a  chronic  condition  :  in  the  so-called 
special  diseases  of  the  blood  and  of  the  blood-making  organs — indeed, 
most  unfortunately,  from  a  diminution  of  the  haemoglobin;  hence,  in 


GENERAL  EXAMINATION.  4X 

chlorosis,  also  in  pernicious  anaemia,  leukaemia,  pseudoleukaemia.  In 
this  list  also  probably  belongs  malarial  cachexia.  Paleness  is  a 
symptom  of  all  slowly-developing  secondary  ayicemias  (cachexia)  as 
they  occur  in  a  large  number  of  diseases,  such  as  all  chronic  febrile 
diseases,  especially  tuberculosis ;  in  suppurations  without  fever ;  in 
continuing  slight  hemorrhages,  as  in  many  tumors  and  in  ankylosto- 
miasis [Egyptian  chlorosis]  ;  in  all  chronic  diseases  of  the  digestive 
tract;  in  most  aiseases  of  the  female  generative  organs;  in  the  dif- 
ferent forms  of  chronic  nephritis,  especially  the  large  white  kidney ; 
in  chronic  poisoning,  especially  by  mercury  and  lead  ;  sometimes,  also, 
in  constitutional  syphilis ;  in  malignant  growths,  especially  in  cancer 
proper ;  and  in  chronic  diseases  of  the  hearty  but  especially  in  fatty 
heart  and  mitral  and  aortic  stenosis. 

In  most  of  these  conditions  there  is,  moreover,  not  only  paleness  of 
the  skin,  but  its  color  has  a  still  further  characteristic  appearance.  In 
severe  anaemias  we  often  have  a  peculiar  waxy  appearance,  which  not 
rarely  has  a  yellow  tone.  A  striking,  light  white  skin  often  exists 
with  the  so-called  large  white  kidney,  also  in  a  certain  proportion  of 
the  cases  of  lead-poisoning  (which  latter  is  often  of  a  grayish  white), 
of  leukaemia  and  of  tuberculosis.  In  chlorosis  the  skin  has  a  greenish 
hue ;  in  diseases  of  the  heart-muscle  and  in  mitral  insufficiency  the 
skin  is  generally  a  smutty  yellow,  while  in  the  cachexia  of  cancer  it 
is  often  gray-yellow. 

In  striking  contrast  is  a  large  development  of  adipose  tissue  in  cases 
of  most  marked  paleness.  This  is  very  often  so  in  diseases  of  the 
blood-making  organs  and  in  heart  diseases.  (It  is  not  to  be  mistaken 
for  oedema,  vide  under  (Edema.) 

2.  Abnormal  Redness  of  Skin. 

This  is  an  expression  of  a  superfluity  of  normal  blood,  since  a 
genuine  plethora  does  not  necessarily  give  rise  to  such  a  condition. 

General  abnormal  redness  of  the  skin  exists  as  a  sign  of  hyperaemia 
of  the  cutaneous  capillaries  in  high  fevers — especially  in  continuous 
fevers.  It  also  is  present  during  the  perspiration  following  a  warm 
bath.  Finally,  in  poisoning  with  atropine,  even  in  very  mild  cases, 
it  is  developed  like  the  redness  of  scarlet  fever.  (The  scarlet-fever 
redness,  being  connected  Avith  a  disease  of  the  skin,  does  not  belong 
here.) 


42  MEDICAL  DIAGNOSIS. 

Local  redness,  depending  upon  a  dilatation  of  the  capillaries,  exists 
very  frequently  in  the  face,  and  indeed  is  physiological  in  those  who 
labor  in  the  sun.  It  comes  and  goes  quickly,  as  in  blushing  (rubor 
pudicitige),  in  nervously  excitable  persons  in  consequence  of  very 
slight  psychical  impressions,  also  not  infrequently  as  a  result  of 
physical  exertion.  Moreover,  we  see  redness  of  the  face  in  fever ; 
finally,  one-sided  redness  of  face  in  the  "paralytic"  form  of  hemi- 
crania. 

Tuberculosis  is  characterized  by  a  very  marked  variation  in  the 
fulness  of  the  capillaries  of  the  face :  if  the  patients  are  entirely  at 
rest  and  without  fever  they  are  generally  pale,  but  under  excitement 
or  exertion,  after  eating,  and,  lastly,  during  fever,  they  exhibit  a  very 
striking,  generally  bright,  redness  of  the  cheeks,  and  often  a  sharply- 
defined  spot  (hectic  redness). 

In  the  slight  forms  of  anaemia,  especially  if  it  is  associated  with 
nervous  irritability  of  heart  (likewise  Avith  local  vasomotor  disturb- 
ances), there  is  sometimes  intense  redness  of  the  face  which  may  con- 
ceal the  anaemia  from  the  physician. 

For  distinction  of  circumscribed  hypersemia  from  hemorrhage  in 
the  skin,  see  under  the  latter. 

3.   Tlie  Blue-red  Skin,  Cyanosis. 

This  is  most  plain  on  the  parts  that  normally  are  bright  red,  hence 
more  than  elsewhere  on  the  mucous  membranes,  on  the  lips,  cheeks, 
etc. ;  also  on  the  knees,  the  phalanges  of  the  fingers,  and  under  the 
finger-nails.  A  moderate  degree  of  cyanosis,  therefore,  would  only 
be  discovered  at  these  parts.  A  marked  degree,  on  the  other  hand, 
exhibits  a  blue  color  spread  over  the  whole  body,  while  those  parts, 
especially  the  mucous  membrane,  become  black-blue. 

The  cyanosis  of  the  newborn,  with  heart-failure,  is  so  striking  to 
the  experienced  observer,  that  it  is  regarded  by  him  as  pathognomonic. 
One  only  sees  anything  like  it  in  the  death  agony,  and,  exceptionally, 
in  severe  spasms  with  marked  interference  with  breathing.  The 
combination  of  cyanosis  with  great  paleness  is  designated  as  "  livid 
skin." 

Cyanosis  arises  from  the  blue-red  color  of  the  capillaries,  and  this, 
as  is  well  known,  is  caused  by  an  accumulation  of  carbonic  acid  and 


GENERAL  EXAMINATION.  43 

deficiency  of  oxygen — that  is  to  say,  by  the  venous  or  hypervenous 
character  of  the  capillary  contents. 

Carbonic  acid  in  the  blood  (serum  and  red  corpuscles)  arises  from : 
1.  Interference  with  the  exchange  of  gases  in  the  lungs.  2.  From 
the  slowing  of  the  capillary  circulation  and  the  consequently  dimin- 
ished gas-exchange  in  the  tissues,  that  is  to  say,  the  diminished  giving 
up  of  COg  by  the  tissues  to  the  blood. 

Cyanosis  arises,  therefore:  1.  In  disturbed  respiration  and  circula- 
tion through  the  lungs ;  2.  In  disturbance  of  the  "  greater  circulation," 
which  may  be  general  or  circumscribed  according  as  the  stoppage  maj 
be  general  or  local.     The  two  causes  may  be  combined. 

Here  belong  to  1  : 

(a)  All  conditions  which  cause  a  narrowing  of  the  larger  air-^ 
jjassages  or  of  a  large  number  of  small  bronchi :  inflammation  of  the 
neighborhood  of  the  pharynx  or  entrance  to  the  larynx ;  retro- 
pharyngeal abscess,  angina  Ludovici ;  very  exceptionally  a  diphtheria 
of  the  throat.  (In  all  of  these  cases  the  interference  with  respiration 
is  either  direct  or  dependent  on  oedema  of  the  glottis.^)  The  following 
are  enumerated :  spasm  of  the  glottis,  paralysis  of  the  dilator  of  the 
glottis  (crico-arytenoideus  post.),  all  acute  and  chronic  inflammations 
of  the  larynx,  but  especially  croup  ;  tumors  of  the  larynx  ;  cicatricial 
narrowing  of  the  larynx ;  foreign  bodies  in  the  larynx  (something 
swallowed  or  vomited) ;  also  foreign  bodies,  croup  and  scars  in  the 
trachea  or  one  or  both  primary  bronchi,  compression  of  these  from 
without  by  enlarged  glands,  aneurism  of  the  aorta,  etc. ;  mediastinal 
tumors,  etc. ;  bronchial  spasm ;  anid  severe  diffuse  bronchitis,  espe- 
cially the  acute  croupous  form. 

ib)  All  diseases  of  the  lungs  and  diseases  in  the  neighborhood  of 
the  lungs  which  hinder  their  expansion  or  wholly  compress  them: 
emphysema  of  the  lungs ;  all  forms  of  consolidation ;  pleuritic  and 
great  pericardial  exudation,  pneumothorax ;  tumors  in  the  chest- 
cavity  ;  abdominal  diseases  with  marked  upward  pressure  of  the 
diaphragm. 

(c)  Paralysis  of  the  respiratory  muscles :  bulbar  paralysis,  periph- 
eral neuritis ;  paralysis  of  diaphragm  from  peritonitis ;  spasm  of  the 

1  A  very  distressing  case  of  suffocation  from  the  lodgement  of  a  large  piece  of  meat 
in  the  pharynx,  and  the  consequent  closure  of  the  entrance  of  the  larynx,  presented 
itself  at  the  Leipzig  medical  clinic. 


44  MEDICAL  DIAGNOSIS. 

muscles  of  respiration,  epilepsy,  tetanus,  but,  on  the  other  hand,  very 
rarely  hystero-epilepsy ;  special  muscular  diseases :  myopathic  forms 
of  progressive  muscular  atrophy,  trichinosis,  myositis  ossificans. 

Disturbances  of  the  circulation  through  the  lungs  occur  in  a  number 
of  the  diseases  which  interfere  with  respiration.  In  emphysema  a  large 
number  of  capillary  channels  are  closed,  also  in  tuberculosis  and  other 
chronic  lung  affections ;  a  large  pleural  exudation  not  only  compresses 
the  lungs,  but  also  the  capillaries.  This  acts  in  the  same  way  as  a 
hindrance  to  respiration. 

(d)  Diseases  of  the  heart  which  result  in  obstruction  of  the  pul- 
monary circulation.  It  is  to  be  noticed  that  in  the  conditions  named 
under  (5)  a  disturbance  of  the  respiration  interferes  with  pulmonary  cir- 
culation. Moreover,  we  must  emphasize  the  fact  that  in  several  of  these 
conditions  (especially  diseases  of  the  pleura,  of  the  peritoneum,  in 
trichinosis  of  the  diaphragm  and  intercostal  muscles)  the  insufficient 
breathing,  as  well  as  the  cyanosis,  will  be  increased  by  the  pain  caused 
by  the  act  of  breathing.  If  the  physician  correctly  recognizes  the 
chain  of  events  he  will  be  able  to  bring  relief  by  the  use  of  narcotics. 

In  persons  very  much  wasted,  especially  from  tuberculosis,  cyanosis 
may  be  absent  even  in  spite  of  the  loss  of  a  large  part  of  the  breathing 
surface  of  the  lungs,  since  the  remaining  normal  portion  suffices  for 
supplying  the  required  quantity  of  oxygen  to  the  diminished  quantity 
of  blood. 

Under  heading  2  : 

Slowing  of  the  hlood-current  in  the  capillaries  of  the  greater  circula- 
tion is  dependent  upon  stopping  of  the  venous  outlet.  This  can  be 
general  and  caused  by  all  the  conditions  of  the  first  category,  general 
cyanosis,  or  it  can  be  occasioned  by  a  venous  stopping  of  an  extremity 
or  of  the  head,  and  so  produce  a  local  cyanosis. 

General  venous  damming  occurs  in  diminished  pumping  power  of 
the  right  ventricle  (valvular  deficiency,  congenital  stenosis  of  the 
pulmonary  artery,  diseases  of  the  heart-muscle,  large  pericardial  exu- 
dation with  hindering  of  the  heart's  action,  considerable  emphysema 
of  the  lungs  with  excessive  damming  of  the  smaller  circulation),  and 
in  the  rare  case  of  compression  of  a  large  venous  trunk  just  before  it 
enters  the  right  auricle  (tumors  of  the  mediastinum). 

Local  venous  stasis  is  caused  by  closure  or  marked  narrowing  of  a 
more  or  less  large  venous  trunk.     This  closure  may  be  produced  by 


GENERAL    EXAMINATION.  45 

compression  or  by  thrombosis  of  the  vein  (compression  of  tbe  cava  or 
the  extremity  of  a  venous  trunk  by  tumors) ;  compression  of  the  cava 
inferior  in  connection  with  the  common  iliac  artery  by  very  large 
effusion  in  the  peritoneum,  or  by  tumors ;  atrophic  thrombosis  of  a 
vein  of  the  extremity,  especially  the  femoral.  Not  infrequently  the 
collateral  veins  of  the  skin  take  up  the  conveyance  of  the  blood  of 
the  venous  stasis ;  they  then  become  enlarged  and  sometimes  tortuous 
{vide  examination  of  the  veins). 

For  the  cyanosis  produced  by  certain  poisons,  see  Examination  of 
the  blood. 

4.   The   Yellow  Skin,  Icterus,  Jaundice. 

The  jaundiced  state  of  the  skin  exists  in  well-marked  cases,  with 
slight  differences,  almost  equally  over  the  surface  of  the  whole  body 
It  is  found  especially  in  the  conjunctiva,  and  in  slight  cases  exclu- 
sively there  and  in  the  other  mucous  membranes,  if  the  observer  will 
render  the  spot  angemic  by  pressure  (best  done  by  means  of  a  micro- 
scopic slide  pressed  upon  the  everted  lip  or  upon  the  tongue).  Ac- 
cording to  the  intensity  of  the  jaundice  the  tissues  are  but  slightly 
tinged  with  yellow,  or  citron  color,  or  yellow-green.  Only  in  very 
severe  cases  (melas-icterus)  does  the  skin  become  green  or  brownish- 
yellow. 

Jaundice  cannot  be  detected  by  the  ordinary  means  of  illumination, 
since  the  yellow,  artificial  light  does  not  enable  one  to  distinguish 
between  white  and  yellow.  In  slight  cases  it  will  first  be  detected  in 
the  conjunctiva.  But  this  must  not  be  confounded  with  the  yellow 
fat  that  sometimes  exists  there,  especially  in  elderly  people.  In 
persons  with  yellow  or  brown  skin  the  jaundice  is  revealed  by  an 
examination  of  the  mucous  membrane. 

The  yellow  color  of  the  skin  after  taking  picric  acid  or  santonine 
has  no  relation  to  jaundice.  We  distinguish  this  condition  from 
jaundice  by  analysis  of  the  urine  {q.  v?)  and  by  the  etiology  of  the 
former. 

Jaundice  of  the  skin  is  the  yellow  coloration  of  almost  the  whole 
body  by  the  coloring  matter  of  the  bile  in  the  blood.  Very  much  the 
most  frequent  form  is  the  jaundice  of  simple  engorgement,  hepato- 
genous or  mechanical  jaundice,  according  to  the  old  designation.  It 
is  occasioned  by  a  primary  biliary  engorgement  in  the  liver,  resulting 


46  MEDICAL  DIAGNOSIS. 

from  a  purely  local  interference  with  the  discharge  of  bile.  This 
interference  is  at  the  ductus  choledochus,  the  transverse  fissure  of  the 
liver,  or  within  the  liver. 

But  there  are  also  so-called  haematogenous  forms  of  jaundice  which 
have  this  in  common,  that  at  the  first  indication  of  the  existence  of 
jaundice  there  is  hsemoglobinsemia,  because  haemoglobin  is  set  free 
from  the  red  blood  corpuscles.  In  many  of  these  cases  (poisoning,  see 
below),  according  to  recent  investigations,  it  is  to  be  assumed  that, 
from  the  decomposition  of  the  red  blood-corpuscles,  there  is  secreted  in 
the  liver  a  very  concentrated,  thick  bile,  and  that  this  cannot  floAV 
through  the  ductus  choledochus,  thus  producing  engorgement  and 
jaundice.  It  is  still  uncertain  whether  this  explanation  can  be  applied 
to  all  cases  of  jaundice  which  are  not  to  be  referred  to  primary  biliary 
engorgement.  It  is  not  inconceivable  (although  more  and  more 
doubtful)  that  hsematoidin  or  bilirubin  (these  two  being  identical)  is 
formed  from  the  haemoglobin  which  has  become  free  within  the  blood- 
vessels.    This  would  be  a  purely  "  blood-jaundice  "  in  the  old  sense. 

In  all  these  cases  the  coloring-matter  of  the  bile  passes  into  the 
urine,  although  when  the  jaundice  is  very  slight  it  may  not  do  so  (see 
particularly  under  2  of  this  section).  The  occurrence  of  the  bile- 
acids  in  the  blood  and  its  appearance  in  the  urine  can,  of  course, 
only  take  place  in  primary  or  secondary  jaundice  due  to  engorgement. 
Hence,  these  would  be  an  infalhble  indication  as  to  whether  the  jaun- 
dice was  due  to  engorgement,  or  was  "blood-jaundice,"  provided 
there  was,  on  the  one  hand,  no  trace  of  bile-acids  in  the  normal 
urine ;  or,  on  the  other,  if  they  very  rapidly  disappeared  after  passing 
into  the  blood.  Thus,  even  in  cases  of  undoubted  engorgement- 
jaundice,  the  bile-acids  might  not  appear  in  the  urine. 

In  very  marked  jaundice  the  coloring-matter  of  the  bile  is  also 
found  in  the  perspiration  and  in  the  saliva. 

It  is  to  be  remarked  that  by  no  means  every  case  of  haemoglobin- 
aemia  results  in  jaundice  ;  sometimes  it  simply  results  in  hsemoglobin- 
uria,  sometimes  also  in  urobilinuria. 

1.  Hepatic  jaundice  is  almost  always  purely  the  result  of  a  biliary 
stoppage.  The  cause  of  the  penning-up  of  the  bile  may  exist  in  the 
bowel;  in  gastroduodenal  catarrh,  with  catarrhal  swelling  of  the 
mucous  membrane,  and  accumulation  of  mucus  in  the  ductus  choled- 
ochus ;  in  tumors  which  press  upon  the  duodenal  orifice  of  the  ductus 


GENERAL  EXAMINATION.  47 

choledochus,  and  especially  cancer  of  the  head  of  the  pancreas ;  in 
ascarides,  or  round-worms  {q.  v.)  which  enter  the  ductus  choledochus ; 
and  also  in  gall-stones,  which  lodge  there. 

There  may  be  compression  of  the  hepatic  duct  or  of  the  large  gall- 
duct  at  the  entrance  of  the  liver  by  tumors  (carcinoma,  echinococcus), 
or  by  scars,  or  by  closure  of  the  same  by  gall-stones.  Closure  of 
many  small  bile-ducts  may  be  caused  by  so-called  intra-hepatic  gall- 
stones ;  possibly  also  compression  of  these  by  marked  damming  in  the 
branches  of  the  veins  of  the  liver  from  general  venous  stasis ;  finally, 
catarrh  of  the  smallest  bile-ducts  may  possibly  cause  bile  stasis  and 
jaundice,  as  in  phosphorus-poisoning. 

In  case  the  flow  of  bile  is  much  hindered  or  is  wholly  stopped,  then, 
partly  from  the  want  of  bile  and  partly  from  the  fatty  contents,  the 
stools  become  light,  perhaps  entirely  white  or  gray-white.  The  par- 
ticulars of  this  condition  of  the  stools  and  of  urine  in  jaundice  are 
explained  in  the  chapters  devoted  to  these  subjects. 

In  some  cases  of  severe  jaundice  there  may  be  still  other  appear- 
ances :  itching,  various  skin  affections,  minute  cutaneous  hemorrhages, 
slowing  of  pulse,  or  simple  nervous  manifestations.  In  very  severe, 
long-standing  jaundice,  there  may  be  marked  heart  disturbances, 
hemorrhagic  diathesis  may  develop,  or,  finally,  there  may  arise  severe 
nervous  manifestations  (cholaemia,  cholsemic  manifestations). 

Moreover,  hepatic  jaundice  may  be  produced  by  the  sudden  diminu- 
tion of  pressure  in  the  portal  vein  while  the  pressure  in  the  bile-ducts 
remains  the  same,  as  at  the  moment  of  birth — icterus  neonatorum 
(Frerichs). 

2.  Hsemato-jaundice,  whose  primary  cause  is  to  be  regarded  as  a 
decomposition  of  the  blood,  takes  place  in  certain  acute  infectious  dis- 
eases (pyaemia,  yellow  fever,  probably  also  sometimes  in  pneumonia) ; 
and  from  certain  poisons  (chloroform,  ether,  chloral,  chlorate  of  potash, 
solution  of  arsenic,  toluylendiamin). 

In  this  case,  as  well  as  in  the  jaundice  of  damming,  there  may  be 
bile  coloring-matter  in  the  urine.  Not  infrequently,  as  in  pyaemia, 
well-marked  signs  of  bile  coloring- matter  may  be  wanting,  and  this 
has  diagnostic  value  for  the  assumption  that  we  have  a  case  of  hsemato- 
jaundice. 

It  is  very  important  to  notice  that  in  real  blood-jaundice  the  flow 


48  MEDICAL  DIAGNOSIS. 

of  bile  into  the  intestine  is  not  disturbed,  and  hence  there  is  no  altera- 
tion of  the  color  of  the  stools. 

JJrohilin-icterus.  In  diseases  of  the  liver,  in  prolonged  hemor- 
rhages of  whatever  nature,  also  in  the  hemorrhagic  diathesis,  finally, 
in  fever,  a  larger  quantity  of  urobilin  is  removed  by  the  urine  (see 
Urine).  Hence  in  rare  cases  a  mild  jaundice  is  observed :  Uro- 
bilin-icterus  (Gerhardt,  Jaksch). 

The  origin  of  urobilin  is  to  be  explained  as  follows :  First  hsema- 
toidin  or  bilirubin  is  formed,  and  then  urobilin  is  formed  from  this  by 
reduction  in  the  tissues  or  in  the  bloodvessels. 

5.   The  Bronze  Skin. 

Unlike  cyanosis  and  jaundice,  this  is  a  condition  pertaining  only  to 
the  skin  and  mucous  membrane.  We  speak  of  the  chief  symptom, 
instead  of  the  true  anatomical  seat,  of  the  disease,  viz.,  the  supra- 
renal capsule — the  so-called  Addison's  disease.  (Very  frequently  it 
is  tubercular.)  [The  association  of  this  peculiar  brown  discoloration 
of  the  skin  is  not  constant  in  Addison's  disease.  It  is  not  so  constant 
in  cancerous,  but  is  more  common  with  cheesy,  degeneration.  The 
latter  condition  may  be  present  without  bronzing  of  the  skin.  On 
the  other  hand,  the  skin  may  be  bronzed,  just  as  "in  Addison's  dis- 
ease without  the  existence  of  cheesy  degeneration  or  any  other  change 
in  the  supra-renal  capsules.  These  facts  have  induced  many  observers 
to  attribute  the  cutaneous  discoloration  rather  to  changes  in  the 
neighboring  sympathetic  nerves — the  solar  plexus  and  the  semilunar 
ganglia.''] 

The  bronze  skin  is  characterized  by  a  brown,  gray  to  black  dis- 
coloration, especially  of  the  face  and  hands.  There  is  also  the  common 
normal  pigmentation  of  the  skin  in  spots.  The  discoloration  may 
gradually  extend  over  the  whole  surface  of  the  body,  only  the  nails 
and  cornea  remaining  clear. 

It  is  very  important  to  notice  that  the  same  discoloration  appears 
upon  the  mucous  membrane  of  the  mouth,  and  more  rarely  upon  the 
^ips,  as  very  sharply  circumscribed,  frequently  quite  small,  brown 
specks. 

The  discoloration  is  caused  by  deposit  of  pigment  in  the  rete  ]Mal~ 
pighii.    Of  course,  pressure  with  the  finger  does  not  at  all  diminish  it. 


GENERAL  EXAMINATION.  49 

6.   The  G-ray  Shin  of  Silver  Deposit. 

After  long-continued  administration  of  nitrate  of  silver  there  may 
be  deposits,  in  certain  organs,  of  very  fine  black  particles  (metallic 
silver  or  silver  albuminate  ?),  as  in  the  kidneys,  intestine,  and  also  in 
the  skin,  and  especially  in  the  corium,  the  tunica  propria  of  the  sweat- 
glands. 

The  skin  of  such  persons,  especially  of  the  face  and  hands,  is  gray 
or  blackish.  The  color  is  not  changed  by  pressure.  In  severe  cases 
we  also  observe  corresponding  gray  specks  in  the  mucous  membrane 
of  the  mouth. 

In  a  strict  sense  this  is  not  a  diseased  condition :  these  people  are 
perfectly  well. 

D.     OTHER    PATHOLOGICAL    APPEARANCES    OF   THE    SKIN    OF    GENERAL 
DIAGNOSTIC   VALUE. 

1.  Acute  Exanthematous  Diseases. 

In  some  acute  infectious  diseases  a  characteristic  eruption  of  the 
skin  has  so  marked  an  appearance  that  these  diseases  are  designated 
as  "  acute  exanthemata."  They  are:  Scarlet  fever,  measles,  German 
measles,  smallpox,  and  varicella.  Here  we  may  pass  over  these  dis- 
eases, since  they  are  closely  connected  with  the  complete  description 
as  they  are  taught  at  the  bedside. 

On  the  other  hand,  there  are  certain  other  acute  exanthematous 
diseases,  less  striking,  but  at  the  same  time  of  great  diagnostic  im- 
portance.    We  may  here  briefly  mention  : 

{a)  Roseola.  This  pres'ents  a  small,  round,  rose-red,  slightly  ele- 
vated spot. 

It  is  generally  scattered,  is  found  most  frequently  upon  the  abdomen 
and  lower  part  of  the  back,  more  rarely  upon  the  breast  and  extremi- 
ties in  typhoid  fever.  It  appears  about  the  beginning,  and  generally 
fades  at  the  end,  of  the  second  week.  Now  and  then  secondary 
roseolar  spots  appear  later,  which  are  connected  with  exacerbations  of 
the  disease  (involving  new  portions  of  the  intestine  ?). 

Secondly,  they  appear  in  most  cases  of  typhus  fever.  But,  except 
in  light  cases,  they  are  in  this  disease  petechial — i.  e.,  the  location  of 
small  hemorrhages,  which  are  slowly  absorbed. 

4 


50  MEDICAL  DIAGNOSIS. 

Further,  they  exist  in  some  cases  of  acute  miliary  tuberculosis,  and 
finally  in  animal  poisoning. 

(h)  Herpes  facialis.  This  consists  of  a  group  of  small  vesicles  upon 
a  slightly  red  base.  The  vesicles  contain  at  first  clear  water,  then  are 
cloudy,  then  yellow  from  pus  contained  in  them.  They  may  be  con- 
fluent. After  a  few  days  they  dry  up  and  scale.  Most  frequently 
this  exanthem  is  found  in  the  neighborhood  of  the  mouth — herpes 
labialis  ;  or  of  the  nose — herpes  nasalis  ;  it  may  also  appear  upon  the 
cheeks  or  the  ear. 

It  makes  its  appearance  at  the  beginning  of  some  acute  diseases 
and  seems  to  be  especially  peculiar  to  very  rapidly  rising  fever.  Above 
all  it  accompanies  croupous  pneumonia,  then  epidemic  cerebro-spinal 
meningitis  (in  this  disease  it  is  often  quite  extensive),  finally,  some- 
times in  angina  (angina  herpetica),  and  a  light  febrile  disease  named 
in  consequence,  febris  herpetica. 

An  herpetic  eruption  also  sometimes  accompanies  the  development 
of  intermittent  fever  and  the  chill  of  pycemia. 

(c)  Miliaria  or  sudamina.  These  are  small,  remarkably  clear  vesi- 
cles, which  reflect  the  light  strongly,  generally  in  large  numbers, 
especially  upon  the  abdomen.  They  appear  if  a  patient,  after  long- 
continued  anhidrosis,  begins  to  sweat  profusely,  especially  in  acute, 
but  also  sometimes  in  chronic,  diseases.  It  is  necessary  to  mention 
them  here  only  because  the  explanation  of  their  diagnostic,  and  like- 
wise pathological,  meaning  ought  to  be  made  prominent. 

Still  other  exanthemata  of  diagnostic  importance  could  be  mentioned 
here,  as  the  (rare)  scarlet  redness  in  the  beginning  of  typhoid  fever, 
the  difierent  eruptions  of  sepsis,  pyoemia,  and  other  diseases. 

2.  Exanthemata  from  Poisons  and  the  Use  of  Medicines. 

These  are  of  varied  character,  since  they  sometimes  resemble  those 
of  acute  diseases,  viz.,  scarlet  fever,  measles,  etc.  They  may,  there- 
fore, easily  cause  an  error  in  diagnosis.  It  is  sufficient  here  to  point 
out  the  diagnostic  importance  of  these  exanthemata.  The  particulars 
regarding  them  belong  to  works  on  diseases  of  the  skin,  and  also  to 
pharmacology  and  toxicology. 


GENERAL  EXAMINATION.  51 

3.  Hemorrhages  in  the  Skin. 

They  arise  chiefly  by  diapedesis,  and  take  place  particularly,  but 
not  exclusively,  in  dependent  parts,  especially  the  lower  extremities. 
They  may  be  of  every  size — from  the  smallest  perceivable  point  to 
the  size  of  the  palm  of  the  hand,  or  even  larger.  The  small,  puncti- 
form  hemorrhages,  eccliymoses  or  petechise,  are  most  apt  to  appear  at 
the  hair-follicles.  The  color  of  fresh  hemorrhages  is  like  venous  blood. 
During  absorption  they  are  brown-red,  later  becoming  bright  brown. 

A  hemorrhage  is  distinguished  from  a  circumscribed  inflammatory 
redness  of  skin  in  that  it  does  not  disappear  upon  pressure.  (The 
small  ecchymoses  in  the  hair-follicles,  mentioned  above,  are  easily 
confounded  with  the  latter,  especially  in  cyanosis ;  further,  petechise, 
in  parts  previously  inflamed,  as  in  measles,  are  easily  overlooked.) 

Simplest  test :  Press  a  piece  of  glass,  a  microscope  slide,  upon  the 
suspected  spot.  A  hemorrhage  is  rendered  more  distinct,  while  the 
surrounding  part  becomes  anaemic ;  an  inflammatory  hyperaemia,  on 
the  other  hand,  disappears. 

Hemorrhages  appear: 

1.  As  evidences  of  a  marked  hemorrhagic  diathesis.  They  are 
then  generally  extensive  in  the  skin,  and,  moreover,  occur  in  con- 
nection with  hemorrhages  from  internal  organs.  They  occur  in 
scorbutus,  purpura  hemorrhagica;  in  severe  acute  infectious  diseases, 
especially  pysemia,  smallpox,  and  scarlet  fever ;  in  acute  phosphorus- 
poisoning  and  acute  yellow  atrophy  of  the  liver ;  and  in  all  severe 
cachexia. 

2.  Without  internal  hemorrhages.,  as  a  condition  limited  to  the 
skin  :  in  peliosis  rheumatica  [^'.  e.,  purpura  occurring  with  severe  pain 
in  the  extremities]  ;  also  as  small  petechioe ;  almost  constantly  in 
typhus  fever  (see  Roseola),  often  in  measles,  and  scarlet  fever ;  more- 
over, on  the  legs  when  the  convalescent  patient  first  stands  up,  espe- 
cially after  typhoid  fever ;  and  in  badly  nourished  persons  where  they 
have  been  bitten  by  pediculi. 

3.  In  marked  venous  stasis,  local  as  well  as  general  (see  Cyanosis). 

4.  As  traumatic  hemorrhages  in  and  under  the  skin.  They  are 
sometimes  of  importance  for  determining  the  occurrence  of  an  injury, 
especially  upon  the  skull. 


52  MEDICAL  DIAGNOSIS. 

4,  Scars. 

These  are  often  important  marks  for  limiting  or  explaining  the 
clininal  history,  which,  by  reason  of  the  scars,  can  be  confined  to  past 
local  or  general  diseases,  or  to  injuries  received. 

Thus  come  under  consideration  "pock  "  (smallpox)  marks  and  the 
scars  which  may  remain  after  the  difierent  scrofulous  and  syphilitic 
diseases  of  the  skin  and  deeper  organs,  especially  the  bones  and 
glands.  In  internal  medicine,  scars  from  injuries  have  importance  in 
many  nervous  diseases  (injuries  upon  the  head,  the  spine,  in  the 
course  of  peripheral  nerves). 

Here  also  belong  the  scars  of  pregnancy,  strice,  upon  the  lower  part 
of  the  abdomen  and  the  upper  part  of  the  thigh.  Exactly  the  same 
scars  occur  in  marked  oedema  (see  the  following  section),  and  also 
sometimes  in  very  fat  persons. 

E.    (EDEMA   OF   THE    SKIN   AND   SUBCUTANEOUS    CELLULAR   TISSUE 
((EDEMA,    anasarca). 

By  these  terms  we  designate  an  abnormal,  marked  saturation  of  the 
tissues  with  fluid,  which  fluid  remains  wholly  or  in  part  distributed  in 
the  cellular  meshes  and  lymph-spaces,  instead  of  a  corresponding 
quantity  of  fluid  existing  in  bulk,  as  its  transudation  takes  place  from 
the  bloodvessels  to  be  removed  by  the  lymph-current. 

(Edema  is  recognized  by  puffiness  of  the  skin  causing  increase  of 
volume  of  the  affected  part,  and  hence,  also,  the  normal  contour,  the 
prominences  of  the  joints,  as  well  as  depressions,  are  obliterated,  and, 
moreover,  there  is  a  tendency  to  an  equal  roundness.  The  skin  is 
smooth,  generally  slightly  shining,  and  hence  very  pale  in  conse- 
quence of  the  diminished  circulation.  It  is  very  noticeable  that  the 
oedematous  tissue  loses  its  elasticity,  so  that  a  depression  made  by  the 
point  of  the  finger  remains  for  a  certain  time,  sometimes  for  hours. 

In  general  or  widely  extending  oedema  it  is  most  manifest  in  de- 
pendent parts,  or  where  the  skin  is  tender  and  the  subcutaneous 
cellular  tissue  is  loose.  Hence,  in  those  persons  who  walk  and  stand 
it  appears  first  at  the  ankles  or  on  the  dorsum  of  the  feet  (not  on  the 
soles  and  toes,  since  here  the  skin  is  too  thick  or  closely  attached ;) 
in  bed-ridden  patients,  on  the  inner  side  of  the  thigh  or  in  the  scrotum 


GENERAL  EXAMINATION.  53 

and  penis,  where  it  is  often  enormous ;  on  the  lower  part  of  the  back  ; 
sometimes  first  of  all,  in  the  loose  cellular  tissue  beneath  the  lower 
eyelid.  One  must  examine  all  of  these  points  if  he  would  detect  the 
first  evidences  of  oedema. 

In  very  marked  cases  the  deeper  parts,  especially  the  muscles, 
become  oedematous ;  the  legs  may  then  attain  enormous  proportions. 
Moreover,  in  marked  general  dropsy  there  are  fluid  accumulations  in 
the  cavities  of  the  body,  giving  rise  to  hydroperitoneum  or  hydrops 
ascites,  hydrothorax,  hydropericardium. 

In  long-continued  oedema  the  skin  of  the  legs  and  the  lower  part 
of  the  abdomen  may  become  thickened,  as  in  elephantiasis. 

We  recognize  three  causes  for  dropsy  of  the  skin  (as  for  dropsy  in 
general)  : 

1.  Venous  stasis  (hydrops  mechanicus). 

2.  Altered  condition  of  the  blood,  particularly  its  becoming  watery. 
8.  Inflammations. 

Hence,  these  corresponding  diseases  cause  oedema  : 

1.  All  diseases,  local  or  general,  which  hinder  the  return  of  venous 
blood  to  the  right  side  of  the  heart,  as  those  that  have  been  already 
mentioned  under  Cyanosis  (see  p.  44). 

In  local  stasis  the  oedema  is  naturally  confined  to  the  roots  of  the 
corresponding  veins,  as,  for  example,  thrombosis  of  the  right  crural 
vein,  causing  dropsy  of  the  right  leg,  or  compression  of  the  vena  cava 
inferior  by  an  abdominal  tumor,  causing  dropsy  of  both  lower  ex- 
tremities. 

2.  All  forms  of  hydrgemia  (ansemia),  acute  and  chronic  nephritis, 
in  which  the  diminished  excretion  of  water,  on  the  one  side,  and  the 
loss  of  albumin  from  the  blood,  consequent  upon  the  albuminuria 
(which  see),  on  the  other  hand,  occasions  the  hydrsemia,  which  is  the 
chief  factor  in  the  condition  which  permits  frequent  and  often  marked 
oedema.  Yet  the  hydrsemia  does  not  always  explain  the  existence  of 
the  oedema  (Cohnheim  and  Lichtheim ;  see  under  Albuminuria). 

All  other  kinds  of  anaemia  (hydrsemia,  see  Blood)  come  under  this 
head  when  they  appear  as  diseases  of  the  blood  or  of  the  blood-making 
organs,  and  are  secondary  to  the  appearance  of  wasting  diseases  and 
severe  acute  diseases  (as  oedema  of  the  ankles,  when  the  convalescent 
patient  first  stands  up). 

The  anaemia  caused  by  long-continued  slight  hemorrhages  (as  those 


54  MEDICAL  DIAGNOSIS. 

occurring  in  ankylostomo-ansemia)  may  also  lead  to  moderate  oedema, 
for  here  also  we  have  hydreemia,  in  that  the  loss  of  blood  is  replaced 
by  water  in  the  blood. 

3.  (Edema,  sometimes  of  considerable  extent,  occurs  in  the  neigh- 
borhood of  inflammation  ("  inflammatory  oedema,"  "collateral  oedema'"). 
This  may  be  of  great  diagnostic  importance,  since  it  sometimes  reveals 
a  deep-seated  inflammation. 

This  is  of  more  interest  to  the  surgeon.  To  the  physician  it  is 
important,  for  instance,  in  pleuritis  with  oedema  of  the  chest- wall.  It 
shoAvs,  with  tolerable  certainty,  that  the  pleuritis  is  purulent.  Deep 
muscular  abscesses  in  severe  diseases,  as  in  typhoid  fever,  may  easily 
be  overlooked,  and  may  first  be  recognized  by  the  appearance  of 
oedema  in  the  neighborhood,  as  along  the  femur. 

The  oedema  in  these  different,  but  so  heterogeneous,  cases  does  not 
have  a  uniform  character :  that  from  stasis  is  sometimes  soft,  some- 
times very  elastic,  the  latter  especially  (in  marked  stasis)  exists  in  the 
extremities,  when  it  is  often  difiicult,  and  sometimes  impossible,  to 
leave  the  mark  of  the  pressure  with  the  finger ;  moreover,  in  cases  of 
nephritis,  with  a  small  quantity  of  urine  and  marked  albuminuria, 
it  is  sometimes  very  considerable,  but  now  and  then  softer.  In  the 
different  anaemias  the  oedema  is  mostly  slight — a  scarcely  noticeable 
pufiiness. 

Slight  oedema  disappears  between  morning  and  evening,  or  evening 
and  morning,  according  to  the  change  of  position  of  the  body. 

The  question,  Why  does  oedema  result  from  venous  stasis,  hydrgemia, 
or  inflammation  ?  has  not  in  all  respects  been  satisfactorily  answered. 
Until  recently  it  seemed  to  be  proved  that  this  is  entirely  to  be 
ascribed  in  these  three  conditions  to  an  injury  of  the  endothelium  of 
the  vessels,  and  by  this  means  occasioning  increased  transudation  into 
the  tissues  (Cohnheim).  Recently  the  view  has  been  advanced,  and 
it  seems  to  me  has  become  well  established,  that  the  loss  of  elasticity 
and  the  diminished  squeezing-out  of  lymph  from  the  tissues  by  their 
being  relaxed  plays  an  important,  perhaps  a  chief,  part  in  causing 
oedema  (Landerer).  This  relaxation  of  the  tissues  might  be  caused 
by  the  stasis  from  the  increased  transudation,  or  by  the  hydraemia 
from  the  deficient  nourishment  of  the  tissues  by  the  morbidly  thin 
blood ;  or,  finally,  it  might  be  caused  by  inflammation  excited  in  the 
neighborhood. 


GENERAL  EXAMINATION.  55 

In  conclusion,  we  must  not  omit  to  mention  that,  in  rare  cases, 
oedema  exists  without  any  other  possible  morbid  disturbance.  Here 
belong  the  essential  oedema  of  children  and  the  oedema  of  the  feet 
after  forced  marches. 


r.    EMPHYSEMA    OF    THE    SKIN. 

By  emphysema  of  the  skin  is  understood  the  entrance  of  air  into 
the  cellular  tissue.  It  may  be  limited  to  one  region  of  the  body,  as 
the  neck  or  the  upper  part  of  the  chest,  or  the  upper  part  of  the 
abdomen.  But  it  may  be  spread  over  almost  the  whole  of  the  body. 
It  is  a  very  rare  condition. 

We  recognize  emphysema  of  the  skin  by  the  very  pale  skin  over  a 
region  which  is  decidedly  elevated  above  its  surroundings.  Indeed, 
on  account  of  the  loose  fixation  of  the  skin  in  certain  parts,  even  de- 
pressions, as  that  over  the  clavicle,  or  the  axillary  space,  or  the  inter- 
costal spaces,  may  he  filled  up,  so  that  sometimes  on  a  first  glance  at 
the  part  it  seems  like  marked  oedema.  Sometimes  at  such  places 
there  may  even  be  an  elevation  of  the  skin  like  a  pillow.  Upon  pal- 
pation we  find  that  the  part  is  very  yielding,  like  a  soft  pillow.  Quite 
unlike  oedema,  however,  the  depression  made  by  pressure  immediately 
disappears.  Moreover,  upon  palpating  the  part,  we  feel  and  hear  an 
unusually  fine  crackling. 

The  so-called  spontaneous  emphysema  of  the  skin  does  not  here 
concern  us.  It  arises  from  decomposition  of  a  blood  extravasation,  or 
abscesses  with  formation  of  putrid  gases. 

The  so-called  emphysema  of  skin  from  aspiration  arises  from  the 
entrance  of  air  or  gas  into  the  subcutaneous  tissue,  either  from  without 
through  a  wound  of  the  skin,  or  from  within  from  an  organ  containing 
air  or  gas. 

{a)  The  entrance  of  air  from  without  after  a  wound  of  the  skin 
belongs  to  surgery.  It  is  especially  observed  in  wounds  of  the  neck, 
of  the  breast,  in  the  lower  part  of  the  face  (so-called  wounds  of  the 
mucous  membrane).  The  wounds  in  question  are  sometimes  remark- 
ably small. 

(h)  Of  much  greater  interest  in  themselves,  as  well  as  from  a  diag- 
nostic point  of  view,  is  emphysema  from  air  or  gas  entering  the  cellular 
tissue  from  within.     Under  all  circumstances  it  is  occasioned  by  the 


56  MEDICAL  DIAGNOSIS. 

rupture,  either  spontaneously  or  traumatically,  of  the  wall  of  an  organ 
containing  air  or  gas.  Hence,  emphysema^  from  "  aspiration ' '  may 
arise — 

1.  From  any  portion  of  the  respiratory  tract,  from  the  larynx  down. 
Deep-seated  ulceration  of  the  larynx  or  trachea  may  invade  the 

walls  of  these  organs,  and  thus  the  air  may  escape  and  enter  the  sub- 
cutaneous cellular  tissue. 

Cavities  of  the  lungs  (after  previous,  repeated  adhesions  between 
the  pulmonary  and  parietal  pleura)  may  ulcerate  into  the  chest-wall, 
until,  jBnally,  communication  with  the  cellular  tissue  is  established. 
Then  the  pressure  of  a  severe  paroxysm  of  cough  may  cause  the  air 
in  large  quantity  to  spread  out  quickly  under  the  skin.  Single  pul- 
monary alveoli  may  burst  from  any  very  high  intra-thoracic  pressure, 
as  severe  cough,  especially  in  children  with  whooping-cough,  bronchitis, 
or  emphysema ;  sharp  crying ;  severe  exertion,  as  blowing  on  wind- 
instruments,  or  women  in  childbirth ;  and  air  may  enter  under  the 
pleura  or  into  the  inter-alveolar  tissue,  reach  the  mediastinum,  pass 
along  the  mediastinal  space  into  the  subcutaneous  tissue  of  the  neck, 
and  so  spread  onward. 

Wounds  of  the  lungs  (as  fracture  of  the  ribs  without  external 
wound)  may  either  directly  cause  emphysema  of  skin,  or,  passing  the 
mediastinum  as  above,  take  the  same  course. 

2.  From  the  oesophagus,  stomach,  or  intestines,  and,  indeed,  from 
the  oesophagus  again  through  the  mediastinum  ;  from  the  stomach  or 
intestines  by  adhesions  with  the  abdominal  wall  and  invasion  of  the 
cellular  tissue  there;  from  traumatic  rupture  of  the  oesophagus,  more 
frequently  from  ulceration,  especially  in  connection  with  carcinoma  of 
the  oesophagus ;  with  any  kind  of  deep-seated  ulcerations  of  the 
stomach  and  bowels. 

Sometimes  there  occurs  extensive  decomposition  of  the  cellular 
tissue,  especially  if  emphysema  of  the  skin  is  produced  by  gases 
from  the  intestinal  canal  (mixed  with  intestinal  contents).  Very  often, 
however,  the  emphysema  remains  without  such  action.  It  may  then 
spontaneously  disappear.  But  at  the  same  time,  the  emphysema  is 
generally  a  final  development,  partly  on  account  of  the  severity  of  the 

1  The  name  "  emphysema  "  is  not  quite  accurate,  since  generally  the  air  is  driven 
in  under  pressure,  as  is  shown  by  what  follows. 


GENERAL  EXAMINATION.  57 

primary  disease,  and  partly  because  it  causes  severe  dyspnoea,  as, 
for  instance,  that  in  the  mediastinum,  and  hence  is  a  very  serious 
condition. 

From  a  diagnostic  point  of  view,  emphysema  of  the  skin  is  of  great 
importance,  since  it  affords  a  conclusion  regarding  the  diseases  men- 
tioned. Under  some  circumstances  it  may  aiford  the  first  and  only 
symptom,  as  in  the  affections  of  the  oesophagus. 

V.  The  Temperature  of  the  Body.     Fever. 

It  is  a  well-known  peculiarity  of  warm-blooded  animals  that  they, 
if  the  organization  is  otherwise  sound,  with  remarkable  constancy, 
maintain  a  certain  internal  temperature  which  is  subject  to  very  slight 
variations.  If  that  peculiarity  is  lost,  if  the  temperature  departs  from 
the  normal,  then,  almost  without  exception,  a  morbid  disturbance  is 
present.  A  knowledge  of  this  fact,  and  especially  of  the  elevation  of 
the  specific  heat  in  disease,  attracted  the  attention  of  physicians  to  the 
temperature  of  the  body  from  the  earliest  time.  Recently,  however, 
the  measurement  of  the  temperature  has  become  of  the  greatest  diag- 
nostic aid.     In  what  way  this  is  so  will  be  explained  at  length. 

1.    The  Terms  Used  and  the  Method  of  Taking  the  Temperature. 

Judging  of  the  temperature  by  laying  on  of  the  hands  is  under  all 
circumstances  deceptive.  Great  errors  cannot  be  avoided  even  if 
covered  parts  of  the  body  are  selected,  while  uncovered  parts  cool  so 
rapidly  as  to  furnish  no  standard. 

We  measure  the  temperature  with  the  Centigrade  or  Celsius's  ther- 
mometer, with  the  scale  divided  into  tenths,  from  about  30°  to  45°. 
There  is  no  need  for  a  thermometer  with  indications  below  30°  (see 
below). 

In  France  the  Reaumur  scale  is  solnetimes  used ;  in  England  and 
America  the  Fahrenheit  is  generally  used.  To  convert  from  one 
standard  to  another  the  following  formula  is  used  : 

1°  C.  =  f  °  R.  =  (9  +  32)°  Fahr. 

It  is  further  to  be  remarked,  that  in  Germany  still,  especially  at 
the  public  baths,  the  baths  are  frequently  measured  and  are  prescribed 
accordins:  to  Reaumur  standard. 


58  MEDICAL  DIAGNOSIS. 

Regarding  the  selection  of  the  instrument,  it  concerns  us  to 
remember  that  there  are  many  incorrect  thermometers.  Exact  com- 
parison Avith  a  standard  at  the  time  of  purchase,  and  at  least  every 
two  years  thereafter,  is  indispensable,  since  all  thermometers  register 
somewhat  higher  with  age.  Thermometers  with  a  cylindrical  column 
of  mercury  are  to  be  preferred,  since  they  are  more  reliable  and  like- 
wise easier  to  use.  Maximal  thermometers  are  strongly  recommended, 
but  the  index  must  work  exactly ;  moreover,  it  is  of  course  always 
to  be  remembered  that  every  time  before  using  the  thermometer  the 
index  must  be  shaken  down  as  far  as  (in  certain  cases  below)  the 
normal  mark. 

When  a  comparison  with  a  normal  thermometer  cannot  be  made, 
an  approximate  determination  may  be  made  by  taking  the  temperature 
in  the  axilla  of  a  healthy  person  upon  say  six  different  days  an  hour 
after  breakfast.  A  thermometer  which  is  correct  in  its  reading  must 
then  give  an  average  reading  of  37°  C.  or  a  little  less  (Liebermeister). 

The  temperature  may  be  taken  in  the  axilla,  the  rectum,  or  in  the 
vagina.  (Taking  the  temperature  in  the  mouth,  and  especially  from 
freshly-passed  urine,  is  to  be  avoided.)  Of  the  three  places  mentioned, 
the  rectum  or  vagina  would  be  preferred,  since  their  temperature  most 
nearly  corresponds  with  that  of  the  inside  of  the  body,  since  the  ther- 
mometer lies  very  equally  in  either  of  these  situations,  and  because  it 
requires  less  time,  the  maximum  being  there  soonest  reached.  But 
from  reasons  of  delicacy  we  only  take  the  temperature  there  when  it 
is  not  possible  to  take  it  in  the  axilla. 

Therefore,  ordinarily,  the  thermometer  is  placed  in  the  axilla  (which 
should  be  first  carefully  wiped  dry,  if  it  is  moist)  as  high  as  possible, 
and  then  the  flexed  arm  should  be  pressed  against  the  chest.  [The 
maximum  is  indicated  in  from  three  to  five  minutes.  Some  thermom- 
eters accurately  indicate  it  in  one  minute ;  but  these  are  so  delicate 
as  to  require  special  care  to  avpid  breaking.  The  thermometer  is  to 
be  left  in  as  long  as  the  index  continues  to  rise.  One  can  easily 
ascertain  how  long  a  given  thermometer  requires  by  testing  it  in  warm 
water  at  various  temperatures.] 

If  the'  patient  is  unconscious  the  arm  must  be  held.  In  cases  of 
marked  unconsciousness,  of  unruly  persons,  and  of  childrenj  it  is  better 
to  take  the  temperature  in  the  rectum  or  vagina. 

If  there  are  fecal  accumulations  in  the  rectum  the  result  is  unre- 


GENERAL  EXAMIXATIOX.  59 

liable.  The  thermometer  is  to  be  oiled  and  passed  in  to  the  depth  of 
about  5  cm.  The  maximum  is  indicated  in  about  five  minutes.  In. 
the  rectum  the  temperature  is  usually  about  0.2°  C.  =  0.36°  F.  higher 
than  in  the  axilla. 

If  the  thermometer  is  not  self-registering,  it  must,  of  course,  be 
read  before  it  is  removed.  iVfter  using  the  thermometer  in  either  the 
rectum  or  vagina  it  must,  in  every  case,  even  "U"hen  there  is  no  infec- 
tious disease  of  either  of  these  organs,  be  carefully  disinfected.  [Xo 
matter  where  the  thermometer  is  used,  it  ought  always  to  be  imme- 
diately cleaned  most  thoroughly.] 

A  single  use  of  the  thermometer  may  be  of  great  value.  But  it  is 
still  more  important,  as  will  be  shown  below,  to  follow  the  state  of  the 
temperature  progressively,  and  to  ascertain  its  course.  For  this  pur- 
pose it  is  necessary  to  measure  it  at  stated  intervals.  How  frequently 
this  must  be  done  in  order  to  ascertain  the  course  of  the  temperature, 
must  be  determined  by  the  particular  disease.  The  thermometer 
should  be  used  at  least  twice  in  twenty-four  hours  (at  about  8  A.  M. 
and  again  at  about  5  P.  M.).  In  diseases  with  high  fever,  according 
to  the  rapidity  with  which  the  oscillations  of  the  temperature  are 
completed,  the  thermometer  must  be  used  every  three  hours,  every 
two  hours,  or  even  hourly.  Where  the  changes  of  temperature  are 
very  marked,  it  may  be  of  interest  to  observe  it  every  quarter-hour. 
It  is  to  be  understood  that,  where  it  is  proper  to  do  so,  the  use  of  the 
thermometer  should,  as  far  as  possible,  be  suspended  at  night,  in 
order  not  unnecessarily  to  disturb  the  patient's  sleep. 

The  record  of  the  course  of  the  temperature  may  be  indicated  by  a 
curve.  Charts  suitable  for  this  purpose  of  various  kinds  are  to  be 
had.  They  serve  also  for  the  record  of  the  pulse  and  respiration. 
Now-a-days,  in  every  case  of  severe  fever,  the  physician  ought  to 
prepare  such  a  fever- curve. 

In  what  folloAYS,  the  statements  regarding  the  temperature  refer  to 
measurements  taken  throughout  in  the  axilla. 

2.   Tlie  Normal  Temperature  of  the  Body. 

The  average  temperature  is  37°  C,  and  varies  from  this  about  1J°: 
from  36.25°  to  37.5°  C. 

The  variations  are  of  different  kinds  and  have  different  causes.  Of 
least  interest,  since  they  are  only  very  insignificant,  are  those  de- 


60  MEDICAL  DIAGNOSIS. 

pendent  upon  age  (in  children,  except  the  day  after  birth,  a  few  tenths 
higher  than  later;  in  old  people,  again,  a  little  higher)  ;  an  elevation 
after  meals ;  an  elevation  after  severe  exertion. 

But  the  periodic  daily  variations  are  more  important.  They  follow 
the  following  course :  In  early  morning,  between  two  and  six,  the 
*' daily  minimum  "  is  reached,  and  then  with  considerable  (not  per- 
fect) regularity  it  rises  to  the  "daily  maximum,"  between  5  and  8  in 
the  evening.  From  that  point  it  again,  during  the  night,  declines. 
The  difference  between  the  minimum  and  maximum,  the  "  daily  dif- 
ference," is  about  1°  C.  (in  rare  cases  even  nearly  2°  C). 

After  severe  exertion,  the  temperature  rises  quite  a  considerable 
amount  higher,  especially  in  the  sun  (Obernier  observed  that  in  the 
case  of  a  person  running  it  rose  to  39.6°  C.)and  in  very  warm  baths. 

3.  Elevated  Temperature.     Fever. 

Every  elevation  of  temperature  which  is  not  dependent  in  a  marked 
way  upon  over-heating  or  severe  exertion  of  the  body,  we  call  fever. 
The  febrile  elevation  of  temperature  is  generally  for  a  certain  dura- 
tion, but  it  may  exist  in  single  cases  as  a  single  short  period,  "  a 
febrile  paroxysm."' 

But  it  is  here  important  to  remember  that  fever  does  not  alone 
consist  of  an  elevation  of  temperature,  but  is  a  complex  symptom, 
whose  separate  manifestations  are  occasioned  partly  by  an  increase  of 
tissue-changes,  partly  by  disturbance  of  the  functions  of  certain 
organs.  To  it  also  belong  the  elevation  of  the  specific  heat ;  also 
general  feeling  of  being  sick,  relaxation,  sometimes  mental  disturb- 
ances ;  increased  frequency  of  pulse  and  respiration  with  exhalation 
of  CO2;  loss  of  appetite,  increased- thirst,  disturbance  of  bowels.  The 
urine  is  generally  diminished  in  quantity,  with  increase  of  excretory 
products  of  the  body,  especially  of  urinary  products,  of  uric  acid  and 
diminished  chlorides.  In  case  the  fever  continues  there  is  notable 
wasting.  Although  a  part  of  these  appearances  may  be  caused  by 
over-heating  of  the  organism,  yet  in  febrile  disease  they  are  doubtless 
not  to  be  regarded  as  simple  results  of  high  temperature.  Hence  it 
results,  among  other  things,  that  the  increased  frequency  of  the  pulse, 

^  The  definition  of  fever  as  "  a  continued  elevation  of  temperature,"  therefore,  is  not 
suitable. 


GENERAL  EXAMINATION.  Q\ 

the  mental  manifestations,  and  the  disturbances  of  the  bowels,  do  not 
have  a  constant  relation  to  the  height  of  the  temperature,  but,  on  the 
contrary,  have  a  markedly  different  expression  according  to  the  cause 
of  the  fever — that  is,  the  nature  of  the  disease.  Nevertheless,  the 
height  of  the  temperature  is  a  very  practical  index  of  the  severity  of 
the  fever,  and  these  two  factors  clinically  become  fully  identified. 
But  the  physician  must  never  forget  to  pay  attention  to  still  other 
manifestations  of  fever  beside-. 

With  reference  to  bodily  temperature,  Wunderlich  has  prepared  the 
following  table : 

I.  Normal  temperature,  37°  to  37.4°  C. 
II.  Subfebrile  temperature,  37.5°  to  38°  C. 
III.  Febrile  temperature, 

a,  slight  fever,  88°  to  38.4°  C; 

6,  moderate  fever,  38.5°  to  39°  C.  morning,  and  39.5°  0. 
evening  ;^ 

c,  considerable   fever,    39.5°    C.    morning,    and   40.5°  C. 

evening ; 

d,  high  fever,  39.5°  C.  morning,  and  40.5  C.  evening. 

[^Qoui'parison  of  Thermometric  Scales: 

Cent.  Fahr. 

34°  93.2° 

35  95 

36  96.8 

Normal  temperature,  37  98.6  Normal  temperature. 

38  100.4 

39  102.2 

40  104 

41  105.8 

42  107.6 

43  109.4] 

If  the  temperature  reaches  42°  0.  then  we  speak  of  hyperpyrexia, 
hyperpyretic  fever.  While  the  higher  temperatures  even  of  high  fevers 
do  not  occasion  direct  danger  to  the  organization,  in  hyperpyrexia 
the  temperature  is  directly  dangerous  to  life ;  it  generally  leads  to  a 
fatal  issue. 

1  Regarding  this  difference  between  raorning  and  evening  temperatures,  see  under 
Remission. 


62  MEDICAL  DIAGNOSIS. 

There  is  uncertainty  regarding  the  highest  temperatures  that  have 
been  observed.  Temperatures  of  45°  C.  have  been  published  as 
curiosities.  One  ease  of  injury  to  the  spine,  which  resulted  in  re- 
covery, is  reported  by  Teale  to  have  repeatedly  had  a  temperature  of 
122°  r.  =  50°  C. 

The  course  of  the  temperature  in  twenty-four  hours  can  vary  much 
only  in  fever.  Most  fevers  show  distinct  fluctuations,  in  that  toward 
morning  the  temperature  falls  more  or  less,  reviission,  until  it  reaches 
the  daily  minimum,  thence  in  the  course  of  the  day  it  rises,  exacer^ba- 
iion,  and  toward  evening  reaches  the  daily  maximum. 

The  difference  between  the  daily  maximum  and  the  daily  minimum 
in  fever  is  called,  as  in  normal  temperature,  the  daily  difference. 
Ys^hile  the  course  of  the  temperature  in  fever  is  analogous  to  that  of 
health,  not  unfrequently  the  minimum  and  maximum  come  at  quite  a 
different  time,  as,  for  instance,  the  maximum  may  be  at  midday  or  at 
midnight ;  a  complete  reverse  may  even  take  place  so  that  the  maxi- 
mum occurs  in  the  morning  and  the  minimum  in  the  evening  :  typus 
inversus. 

From  this  it  is  seen  how  the  temperature  must  be  exactly  measured 
every  hour  of  the  day  and  night  if  it  is  of  importance  to  know  whether 
a  patient  has  fever  or  not.  There  have  been  cases  when  the  persons 
were  thought  to  be  without  fever  until  the  physician  thought  of  ascer- 
taining the  temperature  at  night. 

The  exacerbation  of  the  fever  is  frequently  connected  with  shivering. 
If  the  temperature  rises  very  rapidly  (it  may  rise  several  degrees  in  a 
single  hour)  generally  there  is  a  chill,  that  is,  a  decided  feeling  of 
chilliness  with  severe  shaking  of  the  whole  body,  chattering  of  teeth, 
when  the  high  internal  temperature  of  the  body  is  then  very  quickly 
contrasted  with  the  subjective  feeling  of  chilliness.  The  skin  is  at 
first  pale,  livid,  and  generally  cool ;  toward  the  end  of  the  chill,  how- 
ever, it  is  regularly  very  hot.  On  the  other  hand,  a  rapid  remission  * 
of  the  temperature  is  generally  accompanied  with  sweats. 

According  to  the  amount  of  the  daily  difference  we  distinguish 
three  types  of  fever:  . 

Continued  fever :  daily  difference  not  more  than  1°  C.  (chiefly  high 
temperature). 

Remittent  fever :  daily  difference  over  1°  C. 


GENERAL  EXAMINATION.  63 

Intermittent  fever :  maximum  very  high,  minimum  within  the 
normal  (or  even  below). 

An  important  peculiarity  of  fever  is  that  the  temperature  does  not 
long  remain  at  the  same  point,  as  it  does  in  health.  It  is  very 
chano^eable.  Warm  clothing,  high  temperature  of  the  room,  and 
sometimes  the  taking  of  nourishment,  cause  a  very  marked  rise  of  the 
temperature  in  fever ;  likewise  also  psychical  influences,  as  fright  or 
anger.  On  the  other  hand,  a*  cool  room  and  (especially)  a  cool  bath, 
also  gradual  loss  of  blood,  as  in  menstruation,  cause  it  to  fall.  It  is 
absolutely  necessary  to  know  this  if  we  wish  to  ascertain  the  cause  of 
many  remarkable  variations  of  temperature  in  fever.  Moreover,  the 
sudden  fall  of  the  temperature  is  sometimes  a  sure  indication  of  an 
internal  hemorrhage. 

4.    The  Subnormal  Temperature. 

It  begins  at  36.25°  C. ;  the  lowest  observed  temperature  is  22°  C. 

1.  It  is  observed  in  febrile  diseases  as  an  expression  of  two  directly 
opposite  conditions,  namely : 

a.  In  a  sudden  fall  of  the  high  fever  with  an  advance  to  recovery, 
the  "  crisis,"  the  critical  decline  of  the  fever.  In  this  case  the  tem- 
perature falls  during  perspiration  sometimes  to  below  34°  C,  and 
only  in  the  course  of  one,  two,  or  three  days  again  returns  to  the 
normal.  We  recognize  the  "  crisis  "  by  the  simultaneous  diminution 
of  the  frequency  of  the  pulse  and  the  respiration,  and  the  feeling  of 
comfort  and  returning  health  by  the  patient. 

h.  In  the  so-called  collapse.  In  this  condition  there  is  generally  a 
very  rapid  fall  of  the  temperature,  and  at  the  same  time  a  sudden 
failure  of  the  heart,  with  (as  is  the  contrary  in  '•  crisis  ")  increase  of 
the  frequency  of  the  pulse,  with  paleness  and  general  failure  of 
strength.  The  condition  of  collapse  may  pass  over,  when  there 
generally  is  an  immediate  rise  of  temperature  again  to  the  former 
point ;  or  it  may  pass  on  to  a  fatal  termination. 

On  the  chart  of  the  fever- curve  the  line  of  the  falling  temperature 
is  crossed  by  the  rising  line  of  the  line  of  the  pulse-curve  in  a  charac- 
teristic way  (see  Pulse).  Sometimes,  in  a  case  of  collapse  ending 
fatally,  the  pulse-line  sinks  parallel  with  the  temperature-line  (see 
Pulse). 

2.  It  occurs  sometimes  temporarily  in  severe  hemorrhages,  also 


64  MEDICAL  DIAGNOSIS. 

sometimes  in  all  kinds  of  chronic  diseases,  especially  in  those  of  the 
heart  and  the  lungs.  If  the  temperature  suddenly  falls,  accompanied 
by  weakness  of  the  heart  and  general  prostration,  then  also  we  speak 
of  collapse, 

3.  Continuing  subnormal  temperature,  extending  into  a  number  of 
weeks,  is  very  rare.  It  may  exist  in  all  severe  wasting  diseases  and  in 
diseases  of  the  brain. 

5.  Diagnostic  Value  of  the   Temperature,  especially/  of  its  G-eneral 

Course. 

Under  certain  circumstances  a  single,  or,  in  other  words,  the  first 
measurement  of  the  temperature  may  be  of  the  greatest  diagnostic 
value.     Of  this  a  few  examples  may  be  given, 

1.  Frequently  the  elevated  temperature,  with  some  indistinctive 
complaints  (or,  in  the  case  of  children,  abstinence  from  food  with  rest- 
lessness), is  the  only  sign  of  a  disease  just  commencing,  or  of  one  that 
has  been  going  on  for  some  time.  Ascertaining  the  temperature  is 
then  of  great  service,  in  that  it  leads  to  a  more  careful  examination 
and  more  extended  observation,  and  to  directing  suitable  care  of  the 
patient.  A  hi^h  morning  tempCTature  points  directly  to  an  acute 
infectious  disease." 

2.  In  marked  cachexia,  without  distinct  organic  disease,  the  exist- 
ence of  temporary  fever  indicates  tuberculosis  with  considerable 
probability. 

3.  A  single  chill  accompanied  with  a  rise  of  the  temperature  to 
about  40°  C,  may,  in  a  given  case,  say  of  a  disease  which  from  expe- 
rience sometimes  causes  suppuration,  lead  to  the  diagnosis  of  suppura- 
tion, as  in  gall-stones,  renal  calculi,  after  injuries  to  the  skull,  as  brain 
abscess ;  also  here  belongs  puerperal  fever,  or,  under  certain  circum- 
stances, it  may  possibly  be  malaria. 

But  the  continued  observation  of  the  course  of  the  temperature  is  of 
still  greater  importance.  It  advances  medical  knowledge  in  various 
ways : 

1,  The  course  of  the  fever  in  a  number  of  diseases  is  so  typical 
that  from  the  temperature  alone  the  diagnosis  may  often  be  made 
with  great  probability,  sometimes  with  certainty.  At  any  rate  it  is 
always,  taken  in  association  with  other  symptoms,  an  important  aid  in 
diagnosis. 


GENERAL  EXAMINATION.  65 

2.  Moreover,  during  the  progress  of  a  febrile  disease,  the  tempe- 
rature not  infrequently  gives  notice,  by  its  unusual  behavior,  of  the 
occurrence  of  an  unusual  event.  Hence,  not  infrequently,  we  first 
become  aware  of  an  exacerbation  or  of  a  complication  in  a  given  dis- 
ease by  a  specially  high  rise  of  the  temperature.  A  sudden  fall  of 
the  temperature  may  give  notice  of  collapse,  or  a  change  to  a  fatal 
issue,  or  an  internal  hemorrhage,  as  of  the  bowels  in  typhoid  fever. 

In  the  following  the  moi^t  important  typical  courses  of  fever  are 
briefly  set  forth : 

1.  Continued  fever  exists  especially  in  two  diseases  :  Typhoid  fever 
and  croupous  pneumonia ;  also  in  typhus  fever,  sometimes  in  erysipelas 
and  miliary  tuberculosis.  In  a  case  of  severe  fever,  with  the  diagnosis 
doubtful,  a  fever  continued  through  several  days  points  with  proba- 
bility to  typhoid  fever ;  and  next  to  acute  miliary  tuberculosis. 

In  abdominal  typhus  [typhoid  fever]  the  fever  rises  for  several  days 
by  equal  steps,  "initial  period'';  reaches  the  summit,  at  which  it 
remains  as  a  continued  fever  one,  two,  or  more  weeks ;  then  it,  as  a 
rule,  gradually  becomes  a  remittent  fever,  of  such  a  character  that  at 
first  the  daily  maximum  remains  high,  with  the  minimum  going  lower 
("the  double  stage"  ["the  long-continued  paroxysm"] — the  mini- 
mum may  even  go  below  the  normal) ;  then  the  defervescence  begins, 

Fis.  1. 
Day  of  illness :  1   2   3   4   5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22 


40° 


37 


Br;KBBBBBSBBBBBBBBBBB8SSBBSaBBBBB7BS'£BV«B 

|aBSBgSBSSS8BSSSBBBSBBBSBBSSSBSifiLaffl7i^^ 

SSBBBBBBBS8888B88aSBB8BBSSBBB|BS8BBBSSB 

—■■■■■—■■■■■■■■■■■■■■■■■■■■■■■■■—■■■■■ 


Initial  period.  Acme.  Defervescence. 

Fever-curve  of  a  regular  mild  typhoid  fever.     (Wundeelich.) 

the  maximum  declining;    this  usually  reaches  the  normal  in  a  few 
days.     The  remittent  and  defervescent  stages  may  be  protracted  for 

5 


66 


MEDICAL  DIAGNOSIS. 


some  time,  even  as  much  as  a  week  :  "  slow  typhus."  Moreover,  the 
temperature  may,  after  it  has  somewhat  declined,  again  rise  :  "  recur- 
rence"; or  the  disease,  after  the  temperature  has  reached  the  normal, 
may  begin  anew,  in  the  same  manner  as  at  first :  "renewing"  (see 
regarding  these  points  Figs.  1,  2,  3). 


Fig.  2. 


Day  of  illness :  13  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35 


Long-continued  paroxysm  of  typhoid  fever. 

There  are  all  manner  of  variations  from  this  behavior  of  the  tem- 
perature in  typhoid  fever,  so  that  a  single  case  seldom  really  pursues 
a  typical  course.     Particular  variations  partly  declare  themselves  by 


Fig.  3. 


40° 

39 

38 

37 
36 


SSSSnSSS&SBmnSSHSBSSSBSSSSSSraSSSSSij 

fas^s;ansssB»Kags»BssaBB9B»:BBRSj 


■.IMBBVAWrill 


■■I 


aj.'B.f.siis;7ABr&vi!iB;iB';»'; 


!■■■ 
■  ■■■ 
!■■■ 


■Ha 

■i! 


Defervescence. 
Typhoid  fever,  with  recurrence  of  fever. 


Second  attack. 


the  earlier  change  of  the  temperature  to  the  changeable  character, 
mentioned  on  page  67  ;  but  the  fever-curve  will  especially  be  affected 


GENERAL  EXAMINATION. 


Ql 


by  the  administration  of  antipyretics.^  But,  particularly,  every 
exacerbation  of  the  temperature  should  cause  the  physician  to  think 
of  complications,  and  a  fall  of  the  temperature,  of  collapse,  and  also 
of  possible  intestinal  hemorrhage. 

In  pneumonia  (see  Figs.  4  and  5)  the  temperature  rises  very 
rapidly  ("initial  period,"  lasting  a  few  hours),  often  accompanied  by 
chill,  then  remaining  as  a  high  continued  fever.  From  this  it  may 
decline,  also  very  rapidly — in  a  few  hours — to  or  below  the  normal, 
with  a  simultaneous  decline  of  the  pulse  and  the  respiration,  and 
generally  with  severe  sweating.     Or  the  defervescence  may  be  some- 


Fig.  4. 

Day  of  illness:   1234          5          6          7          8           niO 

■■■■■■■■■■■■■■■■■■H 

HHHHHHHHIHHHHHIHHHHHH 

HHHMHHHHHHHHHHHHHHIBi 

4(  o 

■■VAnHHHHrAlHr^HHBHaBH 

■MMBHFilHBiamHMnHHHBHH 

■  KrjH.VllHKKHiWflllHBHBBH 

■■■■WBMHMHkVBRMBHHHH 

■■■■riBWMHVMIIHHBHHH 

"Vi 

■■■■HBHMHBMmiHBHHHH 

■■■■■■■   a55BE!S999BB 

■!■■■■■■     ■■■BBIBBHHHH 

Cto 

■MBHBBnaBBBHBIBHBHgg 

■(■■■BailiBBBBBWBBBBBB 

■{■■■BMIU     ■BBBHIBBBBBB 

o8 

■IBBBBHI'I     ■■■■■■■BBBB 

IIBBBBBB     BBBBBBHBBBB 

IIBBBBBH     ■■■BBBHBBBB 

IIBBBBBB     BBBBBlHBBBBB 

0*7 

6i 

iSSSSBSB  SSSbbISBbbbb 

BBBBBBB     BBBBBMBBBBB 

BBBBBHH     ■BBBBMBStlBfiiiri 

BBsalss  SSsSbbBBs 

36 

Pseudo-crisis. 
Fever  curve  of  croupous  pneumonia.     (Strumpell.) 


what  slower,  occupying  one  or  two  days.  The  former  way  is  called 
"  crisis  "  (critical  sweat),  the  latter  "lysis";  midway  between  these 
two  is  "  protracted  crisis." 

Sometimes  the  day  before  the  crisis  the  temperature  suddenly  falls 
very  rapidly,  and  then  again  rises — "  pseudo-crisis "  (distinguished 

1  The  antipyretic  treatment,  especially  with  internal  remedies,  has,  no  doubt,  the 
result  of  rendering  the  course  of  the  fever  untypical,  and  so  destroying  its  diagnostic 
value.  Therefore,  until  the  diagnosis  has  been  established  in  a  case  of  febrile  disease, 
the  internal  antipyretic  treatment  ought,  if  possible,  to  be  suspended* 


68 


MEDICAL  DIAGNOSIS. 


from  collapse  by  the  pulse  and  the  general  condition,  as  referred  to 
under  "the  subnormal  temperature").  Or  there  is  exacerbation  of 
the  temperature  just  before  the  crisis,  rising  from,  say,  40°  to  41°  C. 
— "  critical  perturbation." 


Day  of  illness:   2 


Fig.  5. 
3      4      5 


Fig.  6. 


itna  — — 

SSSBSIS  BBSS 

iSwif 

iSii'j  HBL 

■■■»■!■■■ 

——-■■■■■wBg 

SSB 


Pseudo-crisis  and  crisis  in  pneu- 
monia.    (WUNDERLICH.) 


Remittent  and  intermittent  fever  (catarrhal 
pneumonia).    (Wunderi.ich.) 


2.  Remitteiit  fever  is  often  met  with.  It  may  exist  some  time 
during  the  course  of  any  febrile  disease.  While  the  temperature  of 
continued  fever  is  generally  high — about  40° — the  fever  may  remit 
whatever  its  height.  If  the  maxima  are  low,  the  minima  may  easily 
be  normal — a  behavior  which,  strictly  speaking,  must  be  considered 
as  intermittent  fever.  Remittent  fever  belongs  especially  to  chronic 
tuberculosis. 

Fig.  7. 


40© 


37 


■■■■SSSllSnBBiiBfiEfSaiiBRHHfiiiiHHn 

■■■iiiBiliBSBHB'iiHr>a'ii.Hri«iiB,'£l!lS9B" 


Hectic  fever  in  tuberculosis  of  the  lungs. 


If  the  maximal  points  of  the  curve  are  high,  the  temperature  often 

falls  pretty  I'apidly,  accompanied  with  chills  and  night-sweats  {hectic 

fever).    Similar  conditions  are  observed  in  the  fever  of  pus-formation. 


GENERAL  EXAMINAJ'ION. 


69 


3.  Intermittent  fever,  in  a  general  sense,  occurs  in  combination 
with  remittent  fever  (see  Fig.  7).  The  hectic  fever  mentioned  above 
as  accompanying  remittent  typlius  [relapsing  fever],  is  often  also  an 
intermittent,  in  which  the  minimum  may  even  be  subnormal. 


Fig.  8. 


2      3 


41° 


40 


39 


38 


37 


■I  ■■■■■■■■■■■ 

■iiiHBHHgagBBB 

alVBBRBSBSr^ 
law  ■!!■■■■■ 


■■■■lilllllllll 

■■■  ■IIHIIANIir 

^iniiiinifJ 

■ni'iilii' 


■■■iviniiii 


«ni 

■iiiiiraHatI 

■illHWMB*" 

■■■IIIBBIMMB'I 

■IIIBIIHBBI 
HIHIIHHW 

■■■UBtlMBBBBH 

■■■■■■■■■■— 


Pysemia  with  rapidly  fatal  course. 

(WUNDERLICH.) 


Fig.  9. 


S  ^^  Mi^  ^^  ^^  i^BH 

■■■■■■■■■■■ 
■■ ■■■■■■■■■ 


llH.BH  ■■■■■ 

■mizzz 

■IIIHIIBI 

■IIIHI|BIII 
■IIIBUHII 
BlilBIIIBni 


SI 


41° 
40 

39 
38 

37 

36 

Quotidian  intermittent  fever. 

(WUNDERLICH.) 


■UHHIBni 

■IIHI 

■U»l 


■■■ 


hSISbS 

■■lira  iiiiiBBBg 
■■■I'B  ■■■■{■■■n 


IIW 

y.ll 


A  peculiar  form  of  intermittent  fever  is  observed  in  pyaemia,  where 
the  temperature  during  chill  may  rise  two,  three,  or  more  times  in 
twenty-four  hours,  and  soon  fall,  with  sweat   and  great  exhaustion, 


Fig.  10. 


Fig.  11. 


41° 


40 


39 


37 


SSBBilBBSBSSSSS 


■  lllBBBfllglWWBB 

■  [■■■■■aiBBIKIBMBBW 

■  IIIBBaillBIIBBI«BflB 

■niBHBUBniggaHag 

■  IIIBBIIIIHIIBBlBBBg 

■  BIBHIHIHIBBUHBg 

■MiBBiniHiiHHnnnB 

IB'BBimailHHIIH'AV 

■■v^'iiaiiBramaKw^HM 

■■nauBwaBBwafati 

■■BBBBBBHiBIBBg 

B  ■■■■»!■  HnMBBB 
BBBBriBBMBBBB 


Tertian  intermittent  fever. 

(WUNDERLICH.) 


40° 


39 


38 


36 


S  '9ES5SSB 

B  IBBSeSBSB 

!  lESBEB 

BBM    (■■■■■■Bl 

BBBB     ■■■BBBBI 

B    BSBB  8BBBBBB 

IBBBBB  8BB7.BBS 

fj  BB  « IB. 

■■     IIBBIi       liKM      ■■■ 

BBSIKIB'^ffillBB  8BB 

BBSi;&.^8ffi.'BB  BSIB 

BHBBAJBBBBB     BBB 

Quartan  intermittent  fever. 

(WUNDERLICH.) 


then  again  rising.     The  pulse  is  generally  very  fi'equent,  and  the 
patient  often  gives  the  impression,  by  the  great  prostration  during  the 


70 


MEDICAL  DIAGNOSIS. 


sweating  stage,  of  going  into  collapse ;  in  fact,  a  condition  of  collapse 
sometimes  exists  with  the  fall  of  the  temperature  (see  Fig.  8). 

In  a  narrower  sense,  however,  we  designate  as  intermittent  fever 
the  course  of  temperature  of  a  special  form  of  malaria.  In  this  there 
is  a  continual  alternation  between  times  without  fever  (apyrexia) ;  a 
quick,  high  rise,  and,  after  a  short  time,  again,  a  rapid  fall  of  tem- 
perature (often  below  normal) — "fever  paroxysm."  Severe  chills 
and  perspiration  accompany  these  attacks  of  fever.  The  attacks  recur 
with  great  regularity,  either  every  twenty-four  hours  (quotidian),  or 
forty-eight  hours  (tertian),  or  seventy-two  hours  (quartan).  Some- 
times the  attacks  recur  one  or  more  hours  earlier  on  successive  days 
(anticipating),  or  they  may  recur  later  each  time  (postponing).  In 
these  forms  of  fever  the  diagnosis  is  made  certain  by  the  fever-curve 
(see  Figs.  9,  10,  11). 

Fig.  12. 


420 

41 

40 

39 

38 

37 

86 


B  ■■■■■■■■■■■■ 
■■■■■■■■■■■I 

-wmxwmwmmmmmmwn 
miivfMwtmmmummmi 

_IMIIlirwnBBHHBHI 

BnirmrAWBiaaBHi 
■JMBUHWIlHiaaHHI 


■■■ItlHIII 
■■■■■■III 
■■■llWill 

■■■rflniiii 

iravHitiii 

■■■niMaii 
rgifjHwaii 

■  ■IflBBBII 

g  ■!■■■■  II 


■■■■■■■■■n 
■■■■■■■■■■■ 

■■■■■■■■■■■ 
■■■■■■■■■■■ 


SSSSSSSBSSSSSSSS5SSSS5SSSSS  "" 

BBB9BBBSS!B'"'"9!SBBBSBSB!J*""""i'*""^&nMSB 


■■■■■WBBHn 

■■■■■■■I 


^rJIWaaHMHHHHH  _. 

■iail'iliaHl*!S?HBIHHHMMI 

■laBanaaHHiiir.iHv^anHi 
■I  mmm  ■■■■avAwraoriHi 


■{■■I 
■■■■I 
ui 


■■■iHaiBriH.viHi 


BBSS: 


BS9B'9BBi'9^'""B*BBi 
BS5SSBB  SBBS>"'''l!"i 
BB9S  BBB'l'B  vtf  vjLTiai 


■■■■■^•'^■•^■■■■■■■■■'■■■riBi^MiW 


mSSSBSS8S8SSBS8SSSSSi 


1.  Apyrexia.  1. 

Febris  recurrens.     (Wundeelich.)     Compare  p. 


2.  Apyrexia. 


4.  Recurrent  fever  only  exists  as  a  renewal  of  a  febrile  disease,  or 
a  disease  known  as  relapsing  fever.  There  is  an  attack  of  fever 
very  like  that  of  pneumonia,  with  sharp  transitions  and  very  severe 
sweating,  the  temperature  falling  often  to  34°  or  35°  C,  and  apyrexia; 
then  a  relapse  after  five  to  eight  days,  with  a  chill,  followed  by  a  high 
continued  fever,  which,  in  turn,  ends  in  five  or  six  days  by  a  critical 


GENERAL  EXAMINATION.  71 

sweat ;  new  apyrexia,  fresh  relapse ;  and  so,  over  and  over  again,  but 
each  new  attack  with  less  fever  and  of  shorter  duration. 

5.  Not  infrequently  a  quite  irregular  fever  will  he  met  with.  Its 
course  is  such  that  sometimes  one  cannot  speak  of  any  daily  remission 
— at  least,  the  lowest  daily  temperature  comes  at  a  variable  hour  of 
the  day  or  night.  But  this  fever  may  be  of  diagnostic  value.  In 
acute  meningitis  a  continuing  irregular  movement  of  the  temperature 
speaks  against  tuberculosis  and  against  ordinary  purulent  meningitis, 
but,  on  the  contrary,  for  epidemic  cerebro-spinal  meningitis.  Again,  a 
pronounced  irregular  fever  in  an  acute  disease  in  general  speaks 
against  any  of  those  diseases  which  manifest  themselves  by  any 
typical  fever. 

6.  Local  Elevation  or  Lowering  of  the  Temperature. 

1.  Elevation  of  the  temperature.  In  internal  medicine  this  is 
seldom  of  diagnostic  aid.  We  meet  it  where  there  is  any  kind  of 
inflammation  which  is  near  the  surface,  as  in  surgery.  In  unilateral 
pneumonia,  also,  a  careful  measurement  shows  an  elevation  of  the 
temperature  in  the  axilla  of  the  aifected  side.  In  recent  paralysis  of 
any  sort  the  temperature  of  that  side  is  somewhat  higher  for  a  short 
time ;  then  the  temperature  usually  falls.  Rare  cases  of  hysteria 
exhibit  a  one-sided  elevation  of  temperature  with  redness  of  the  skin 
and  perspiration. 

2.  Lowering  of  the  temperature.  This  is  the  expression  of  local 
disturbance  of  the  circulation.  In  heart-failure,  also  in  collapse  and 
near-approaching  death,  the  extremities  and  also  the  nose  become 
cool.  Coolness  of  the  aff'ected  limb  is  observed  in  venous  thrombosis, 
in  paralysis  of  long  standing  in  consequence  of  diminished  venous 
blood-current,  and  in  arterial  embolism  and  thrombosis. 


PART    III. 
SPECIAL  DIAGNOSIS. 


CHAPTER    lY. 

EXAMINATION  OF  THE  RESPIRATORY  APPARATUS. 

Examination  of  the  Nose  and  Larynx. 

1.   The  Nose. 

Inspection  of  the  nose  sometimes  reveals  diseased  conditions  which 
concern  the  bony  structure,  and,  therefore,  belong  to  surgery :  defor- 
mities, fistulse,  ulcers,  with  deeply- seated  destructive  process  at  the 
root  of  the  nose. 

Only  one  of  these  conditions  has  interest  for  us  as  physicians :  the 
so-called  saddle  nose,  arising  from  necrosis  and  removal  of  a  part  of 
the  bony  framework  of  the  nose,  is  an  almost  infallible  sign  of  consti- 
tutional syphilis. 

Swelling  and  redness  of  the  nostrils  indicate  inflammation  of  the 
nasal  mucous  membrane.  Not  infrequently  we  also  see  traces  of  a 
muco-purulent  or  purulent,  sometimes  an  ill-looking  bloody,  serous 
secretion ;  the  latter  is  sometimes  offensive  in  odor. 

Patients  with  obstructed  nose  (with  severe  catarrh  or  tumors) 
breathe  through  the  mouth.  On  the  other  hand,  in  severe  dyspnoea 
[q.  V.)  there  is  likewise  motion  of  the  alae  nasi. 

JEpistaxis  shows  itself  most  plainly  by  the  flow  of  blood  from  the 
nose.  However,  when  persons  are  entirely  unconscious  or  healthy 
persons  are  asleep  upon  the  back,  the  blood  flows  backward  into  the 
pharynx  or  even  into  the  stomach.  Then  the  hemorrhage  may  be 
overlooked,  or  the  first  symptom  of  epistaxis  may  be  vomiting  of 

blood. 

(73) 


74  SPECIAL  DIAGNOSIS. 

In  all  important  diseases  of  the  nose  it  is  necessary  to  make  use  of 
the  nasal  speculum.  (For  the  use  of  this  in  examinations,  see  the 
Appendix.) 

Palpation  of  the  interior  of  the  nose  may  be  necessary  (see  works 
upon  Surgery). 

Acute  muco-purulent  and  purulent  catarrh  of  the  nose  is  symp- 
tomatic in  measles,  diphtheria,  and  equinia.  Chronic  catarrh  is  a 
common  symptom  of  scrofula  (in  which  disease  the  whole  nose  is  often 
swollen)  and  of  syphilis.  In  the  former  disease  there  is  sometimes  an 
inflammatory  thickening  of  the  whole  nose,  particularly  of  its  lower 
walls.  Inflammation  of  an  acute  form,  with  very  foul-smelling  and 
ill-looking  secretion,  most  frequently  indicates  diphtheria  of  the  nose 
and  pharynx. 

2.   The  Larynx. 

The  larynx  is  examined  with  reference  to  its  functions  (voice, 
cough,  breathing)  and  the  local  appearances ;  the  latter  includes  the 
external  and  internal  examination  (see  also  under  Sputum). 

(a)  The  Function. — The  voice  is  changed  in  all  afiections  of  the 
larynx.  It  may  be  muflied,  rough,  hoarse,  even  to  the  entire  loss  of 
voice — "  aphonia."  In  severe  diseases  it  may  have  a  whistling  or 
sibilant  (strident)  quality  :  This  indicates  stenosis  of  the  larynx ;  or  it 
is  very  hoarse  and  deep :  this  points  to  deep-seated  ulceration. 

In  diseases  of  the  larynx  the  cough  is  hoarse,  loud,  or  barking. 
In  extensive  destruction  and  in  certain  paralyses  of  the  crico-aryte- 
noid  muscles,  cough  is  either  more  difficult  or  is  impossible,  since  the 
power  to  close  the  glottis  preceding  the  cough,  as  is  normally  the  case, 
is  wanting  (see  Cough). 

Breathing  is  obstructed  in  all  conditions  that  narrow  the  larynx,  as 
in  inflammation  resulting  in  hypertrophy,  in  new  formations,  in  scars 
with  contraction.  Then  there  is  an  inspiratory  and  expiratory 
dyspnoea  (which  see),  and  a  peculiar  noise  of  stenosis,  "  stridor  laryn- 
geus."  In  marked  stenosis,  especially  when  the  thorax  is  weak,  as  in 
children,  there  is  a  drawing-in  of  the  lower  part  of  the  thorax  in 
front,  in  the  region  of  the  insertion  of  the  diaphragm  (see  the  chapter 
on  Anomalies  of  Respiration). 

Stenosis  only  in  inspiration,  causing  inspiratory  dyspnoea,  is  ob- 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.  75 

served  in  paralysis  of  the  crico-arytenoid  muscles,  the  dilators  of  the 
larynx. 

Laryngeal  stenosis  is  distinguished  from  tracheal  stenosis  at  the 
first  glance,  in  that  in  the  former  condition  the  larynx  moves  up  and 
down  with  each  breath,  and  the  neck  is  stretched  to  the  fullest  extent, 
while  in  the  latter  the  larynx  remains  quiet  and  the  head  is  always 
somewhat  bent  forward. 

(h)  Local  Examination.- — The  external  examination  is  made  with 
reference  to  pain,  to  deformities  revealed  to  the  sight  or  touch  (these 
are  very  rare,  resulting  from  destruction  by  periostitis),  and  laryngeal 
fremitus. 

Laryngeal  fremitus  is  a  trembling  of  the  thyroid  cartilage  during 
speech.  It  is  stronger  or  weaker  on  one  side  in  unilateral  paralysis. 
It  has  no  special  diagnostic  value. 

The  internal  examination.  By  great  care,  and  in  the  case  of 
patients  who  have  themselves  under  good  control,  sometimes  the 
entrance  to  the  larynx  and  the  tissues  even  as  far  as  the  glottis  can 
be  touched.  This  method,  however,  has  now  little  value,  since  it  has 
been  entirely  superseded  by  the  examination  with  the  laryngeal  mirror, 
which  is  the  best  means  of  examining  the  larynx.  (Regarding  its  use 
see  the  Appendix.) 

In  inflammatory  conditions,  patients  complain  of  pain  in  speaking, 
but  sometimes,  even  with  severe  disturbances,  there  is  no  pain ;  now 
and  then  there  is  dyspnoea,  especially  on  exertion.  Pain  in  sivallow- 
ing  in  chronic  diseases  of  the  larynx  frequently  indicates  serious  con- 
ditions :  extension  of  new  formation  (carcinoma)  toward  the  oesophagus, 
or  destructive  suppuration. 

The  leading  symptomatic  indications  of  diseases  of  the  larynx  with 
reference  to  other  possible  internal  diseases,  are  as  follows :  acute 
laryngitis,  with  manifestations  of  an  acute  infectious  disease,  points 
especially  to  measles,  croup  (and  also  to  smallpox).  Chronic  laryn- 
gitis points  to  tuberculosis  and  syphilis ;  to  constriction  by  scars,  to 
syphilis.  Of  paralyses,  paralysis  of  the  recurrent  nerve  is  of  special 
diagnostic  importance,  since  it  often  arises  from  pressure  upon  nei'ves, 
especially  upon  the  left  side  from  aneurism  of  the  aorta,  carcinoma 
of  the  oesophagus,  tumors  of  all  kinds  in  the  mediastinum.  Certain 
paralyses  indicate  hysteria. 


76  SPECIAL  DIAGNOSIS. 


Examination  of  the  Lungs, 
topographical  anatomy  of  the  lungs. 

For  localizing  the  surface  of  the  chest  with  reference  to  height  and 
depth  Ave  make  use  partly  of  anatomical  prominences  and  partly  (for 
determining  the  breadth)  of  certain  local  lines  which  we  think  of  as 
drawn  upon  the  surface  of  the  thorax. 

Upon  the  front  side  of  the  thorax  are  the  important  anatomical 
regions :  the  fossa  supraclavicularis  (above  the  clavicle  and  bounded 
by  the  sterno-cleido-mastoid  and  trapezius  muscles)  and  the  fossa  in- 
fraclavicularis.  The  latter  has  no  distinct  lower  boundary.  We  under- 
stand it  as  the  region  immediately  below  the  clavicle,  about  as  far  as 
to  the  second  rib.  From  the  second  rib  downward  we  designate  the 
height  by  the  ribs  and  intercostal  spaces :  as  above  the  fourth,  under 
the  fourth  rib,  the  fourth  intercostal  space.  The  number  of  the  par- 
ticular rib  is  determined  by  counting  from  the  second  rib  downward. 
It  is  always  easy  to  find  this  rib  :  it  is  in  articulation  with  the  sternum 
exactly  where  the  manubrium  and  corpus  sterni  unite,  ordinarily 
forming  a  very  slight  angle  (angulus  Ludovici),  and  this  place  is 
plainly  to  be  felt,  and  often  seen,  as  a  cross-line  or  prominence.  We 
feel  for  this  prominence  and  find  the  second  rib  to  be  its  prolongation. 
"We  count  the  ribs  from  that  downward,  feeling  somewhat  obliquely 
outward  as  we  go  down.  Morenheim's  depression  [the  outer  part  of 
the  infraclavicular  depression]  and  the  so-called  Sibson's  furrow  (the 
under  border  of  the  pectoralis  major)  are  sometimes,  although  not  very 
practically,  useful  as  points  for  locating  internal  organs. 

For  determining  the  breadth  the  vertical  lines  now  to  be  mentioned 
are  useful  (the  subject  is  supposed  to  be  standing) :  the  middle  line, 
drawn  through  the  sternum ;  the  two  sternal  lines,  drawn  parallel 
along  the  sides  of  the  sternum  ;  the  mammillary  lines,  drawn  through 
the  male  nipple ;  and  the  parasternal  lines,  drawn  midway  between 
the  sternal  and  the  mammillary  lines. 

On  the  two  sides  we  determine  the  height  by  the  ribs,  which  we 
count  in  front ;  and  the  breadth  by  the  middle  axillary  line  (drawn 
through  the  middle  of  the  axilla,  the  arm  being  extended  sidewise), 
the  anterior  and  posterior  axillary  lines  (drawn  perpendicularly  from 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.  77 

the  points  where  the  pectoralis  major  and  latissimus  dorsi  muscles 
leave  the  thorax,  with  the  arm  raised  sidewise  to  the  horizontal). 

Upon  the  back,  we  name  the  fossa  supraspinata ;  above  that,  the 
suprascapular  space ;  the  fossa  infraspinata ;  the  interscapular  space, 
between  the  two  scapulae  ;  the  infrascapular  space,  under  the  shoulder- 
blades.  Exact  determination  of  height  is  made  by  counting  the  ribs, 
which,  however,  are  difficult  to  count,  especially  in  fat  persons.  They 
can  be  determined  by  three  methods : 

(a)  By  counting  the  vertebral  prominences  from  the  vertebra 
prominens  (the  seventh  cervical). 

(h)  By  counting  from  the  lower  angle  of  the  scapula ;  this  over- 
hangs the  seventh  rib  in  the  average  person  when  the  shoulders 
hang  comfortably  and  the  arms  rest  against  the  chest  with  the  fore- 
arms folded  lightly. 

((?)  By  the  point  of  the  twelfth  rib,  which  is  easily  felt  (the  best 
way  for  the  lower  ribs). 

Moreover,  we  have  the  scapular  line,  which  is  drawn  upon  the  two 
sides  of  the  spine  through  the  lower  angle  of  the  scapulae  (at  the  point 
already  mentioned  under  (5)), 

It  is  to  be  observed  that  some  of  the  vertical  lines  are  not  deter- 
mined exactly.  This  is  true  regarding  the  mammillary  line  (always 
very  important)  more  than  any  other.  In  women  it  is  generally  very 
variable.  On  this  account  it  is  always  to  be  thought  of  as  drawn  upon 
a  male  thorax.  But  even  in  the  male  the  nipple  is  an  uncertain 
point.  By  much  practice  the  eye  is  cultivated  so  as  to  recognize 
what  is  to  be  regarded  as  the  average  location  of  the  nipple  in  the 
male,  and  by  this  we  must  always  correct  the  mammillary  line.  The 
attempts  to  substitute  other  lines  for  this  one  have  not  been  accepted. 

The  designation  "  infrascapular  space  "  is  little  used.  The  expres- 
sions, "  right,  left ;  behind,  below,"  correspond  to  it,  and  are  much  to 
be  recommended :  behind  or  below  the  right,  the  left,  scapula. 

THE    A^'ATOMICAL    BOUNDARIES    OF    THE    LUNGS    WITH    REFERENCE 
TO    THE    THORAX. 

In  front  the  lungs  reach  to  the  sixth,  and  behind  to  the  tenth,  rib, 
and  are  almost  everywhere  directly  in  contact  with  the  chest-wall. 
They  afe  not  in  contact  with  the  chest-wall  in  the  neighborhood  of  the 
heart  nor  behind  a  small  portion  of  the  upper  part  of  the  sternum. 


78 


SPECIAL  DIAGNOSIS. 


The  accompanying  figure  exhibits  the  anatomical  boundaries  of  the 
lungs.  They  project  with  their  summits  into  the  fossa  clavicularis 
from  three  to  five  cm.  above  the  clavicle,  and  with  their  inner  anterior 
borders  converging  downward,  so  that  behind  the  angulus  Ludovici, 
not  exactly  behind  the  middle  of  the  sternum,  but  a  little  to  the  left, 
they  come  to  lie  very  close  to  each  other ;  then  they  continue  parallel 

Fig.  13. 


Position  of  the  thoracic  viscera,  of  the  stomach  and  of  the  liver,  from  in  front.  The 
portions  of  the  heart  and  liver  which  are  drawn  with  unbroken  hatched  lines  represent 
the  parietal  portions  of  those  organs.  The  portions  that  are  not  in  contact  with  the 
chest- wall,  but  are  covered  by  the  lungs,  are  represented  by  broken  (clear)  hatched 
lines.     The  line  ef,  border  of  the  right  lung;  g  h,  border  of  the  left  lungj  dotted  lines 

( )  a  h  and  c  d,  the  boundaries  of  the  complementary  pleural  space  ;  i,  the  boundary 

between  the  right  upper  and  middle  lobes;  k,  the  boundary  between  the  right  middle 
and  lower  lobes  of  the  lung;  I,  boundary  between  the  left  upper  and  lower  lobes; 
w,  greater  curvature  of  the  stomach.     (Weil-Luschka.) 

downward  to  the  insertion  of  the  fourth  rib.  From  there  the  inner 
border  of  the  right  lung  proceeds  still  further  downward  to  the  top  of 
the  insertion  of  the  fifth  rib,  then  gradually  bends  toward  the  right  so 
that  it  follows  along  the  sixth  rib,  on  the  upper  border  of  which  it 
meets  the  mammillary  line.     Then  it  continues  approaching  the  hori- 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS. 


79 


zontal  (in  the  upright  posture)  so  that  it  lies,  in  the  middle  axillary 
line,  upon  the  seventh  or  eighth  rib,  in  the  scapular  line  upon  the 
tenth  rib  (this  location  on  the  dead  body  is  about  one  cm.  higher  than 
in  quiet  respiration  in  the  living  subject).  On  the  left  side,  the 
border  of  the  lung  bends  sharply  round  from  the  fourth  rib  to  give 
place  to  the  heart,  continues  behind  the  fourth  rib  as  far  as  the  left 

Fig.  14. 


Position  of  the  lungs,  liver,  spleen,  and  kidneys,  seen  from  behind.     The  liver  and 
spleen  are  represented  by  the  same  hatching  as  in  Fig.  13.     a  h,  the  lower  border  of  the 

lungs  J  cd{ ),  complementary  space;  i  (dotted  line)  (broken  line),  border  of  the 

liver;  ef  (dotted  line),  boundary  between  the  upper  and  lower  lobes  of  the  lungs; 
g,  boundary  between  the  upper  and  middle  lobes  of  the  right  lung.     (Weil-Luschka.) 

parasternal  line,  then  bends  vertically  downward,  making  a  small  bow, 
which  converges  toward  the  right;  then  sharply  bending  again  behind 
the  sixth  rib  so  as  to  pass  the  mammillary  line  under  the  sixth  rib 
(hence,  somewhat  lower  than  on  the  right  side),  it  passes  the  axillary 
line  between  the  seventh  and  eighth,  and  the  scapular  line  at  the  tenth, 
rib. 

The  boundaries  of  the  lungs  are  different  according  to  age,  as  well 
as  in  individuals.    (See  section  on  Percussion  of  the  Lungs.) 


80  SPECIAL  DIAGNOSIS. 

The  boundaries  of  the  pleural  sacs — that  is,  the  lines  on  which  the 
pleura  costalis  (sternalis)  leaves  the  wall  of  the  thorax  and  bends  inward 
— agree  in  reality  with  the  course  of  the  inner  borders  of  the  lung. 
But  along  the  lower  borders  of  the  lungs  and  at  the  cardiac  concavity 
the  pleural  space  extends  considerably  beyond  the  border  of  the  lungs 
(in  quiet  breathing),  making  the  sinus  phrenico-costalis  and  the  comple- 
mentary pleural  sinus  The  size  of  these  corresponds  with  the  form. 
The  largest  is  the  complementary  pleural  sinus  in  the  two  axillary 
lines.     This  is  there  about  ten  cm.  high. 

The  pleural  sinuses  are  therefore  important,  since  into  them  extend 
the  lungs  at  every  deep  inspiration  and  also  in  the  pathological, 
chronic  inflation,  emphysema  pulmonum;  and  also,  because  in  them 
fluid  eff'usions  into  the  pleural  cavity  ordinarily  first  accumulate. 

The  under  surface  of  the  lungs  rests  directly  upon  the  diaphragm. 
The  diaphragm  in  the  dead  body  rises  at  its  highest  part,  as  a  dome, 
about  as  high  as  the  insertion  of  the  fourth  rib,  a  little  higher  upon 
the  right  than  the  left  side.  The  average  situation  of  the  dome  of  the 
diaphragm  in  life,  during  quiet  breathing,  is  a  little  lower. 

Finally,  it  is  necessary  to  mention  the  course  of  the  boundaries  of 
the  lobes  of  the  lungs,  since  they  sometimes  have  an  important  part  in 
diagnosis:  at  the  back,  near  the  spine,  the  boundary  between  the 
upper  and  lower  lobes  is  at  the  height  of  the  lower  angle  of  the 
scapula ;  upon  the  left  it  gradually  slopes  forward  and  outward  in  such 
a  way  that  in  the  axillary  line  it  stands  at  the  fourth  rib,  and  meets 
the  lower  border  of  the  lung  (that  is,  at  the  sixth  rib)  in  the  mammil- 
lary  line.  On  the  right  side  the  boundary-line  divides  near  the  outer 
border  of  the  scapula  into  two  diverging  lines :  the  line  between  the 
upper  and  middle  lobes  and  that  between  the  middle  and  lower  lobes. 
The  former  proceeds  at  first  behind  the  third  rib,  and  terminates  at  the 
inner  border  of  the  lung  at  the  insertion  of  the  fourth  rib  ;  the  latter 
meets  the  lower  border  of  the  lung  somewhat  within  the  mammillary 
line,  and,  therefore,  behind  the  sixth  rib. 

Hence,  in  front  upon  the  right  side,  we  have  the  upper  lobe;  about 
at  the  third  intercostal  space,  from  there  downward  really  the  middle 
lobe;  in  front  on  the  left  side,  for  the  whole  distance  we  really  have  the 
upper  lobe ;  on  the  side  at  the  right,  we  have  the  middle  lobe  above 
and  the  lower  lobe  below ;  on  the  side  at  the  left,  we  have  the  lower 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.  gl 

lobe ;  behind  we  have  only  the  apices,  formed  by  the  upper  lobes ;  all 
the  rest  is  lower  lobe. 


INSPECTION    OF    THE    THORAX. 

The  examination  of  the  thoracic  organs  must  always  begin  with  the 
inspection  of  the  thorax.  Nothing  is  more  faulty  than  to  take  up 
some  other  method  of  examination  first.  Inspection  of  the  thorax  is 
important  because  a  very  large  number  of  the  diseases  of  the  lungs 
and  pleura  manifest  themselves  in  the  form  of  the  chest  cavity  and  a 
change  of  the  respiration.  Certain  diseases  of  the  internal  organs 
have  a  causal  relation  to  changes  in  the  form  of  the  thorax.  In  other 
cases,  as  it  appears,  a  given  form  of  thorax  accompanies  a  "disposi- 
tion "  of  the  lungs  to  certain  diseases  (emphysema,  phthisis).  It 
is  very  probable,  although  it  is  difficult  positively  to  establish,  that 
sometimes  the  thorax  by  its  form  either  causes  or  favors  the  develop- 
ment of  the  given  disease.  Moreover,  we  know  that  there  are  deform- 
ities of  the  chest  which  in  other  ways  injure  or  render  useless  the 
thoracic  organs ;  there  are  such,  also,  as  have  no  influence  upon  the 
lungs  or  heart. 

Method  of  procedure.  During  inspection  (as  in  all  examinations 
of  the  thorax)  attention  must  be  given  to  having  the  patient  straight, 
but  without  undue  muscular  tension.  The  light  should  fall  symme- 
trically upon  the  front  or  back,  whichever  is  under  examination ;  the 
eyes  of  the  examiner  should,  if  possible,  be  directly  before  the  middle 
line  of  the  body.  The  general  structure  of  the  thorax  (and  neck) 
should  first  be  considered,  next  possible  peculiarities,  then  the  motions 
of  respiration,  first  during  quiet,  then  deeper,  respiration. 

1.  Normal  Form  of  Thorax  and  Normal  Respiration. 

In  a  well-constructed  thorax  we  expect,  first,  perfect  symmetry 
(this  is  departed  from  almost  always  normally,  in  that  there  is  a  very 
slight  curvature  of  the  dorsal  vertebrge  toward  the  right).  Moreover, 
the  clavicular  depressions  may  only  be  indicated ;  the  angulus  Ludo- 
vici  [also  called  the  angle  of  Louis]  (the  angle  formed  by  the  junction 
of  the  manubrium  and  corpus  sterni)  may  just  be  recognizable;  the 
true  ribs  should  so  leave  the  sternum  that  from  the  top  downward  there 

6 


g2  SPECIAL  DIAGNOSIS. 

is  increasing  obliquity,  making  the  angle  formed  by  the  two  opposite 
bendings  of  the  ribs,  "  the  epigastric  angle,"  almost  a  right  angle ;  the 
thorax  should  be  well  developed ;  the  scapulae  should,  in  the  upright 
position,  lie  flat  upon  it ;  the  intercostal  spaces  should  be  visible  only  at 
the  lower  ribs ;  finally,  the  dimensions  of  the  chest  and  the  size  of  the 
body  should  have  a  certain  relation  to  each  other.  Very  seldom  does 
the  normal  thorax  correspond  to  this  ideal,  and  there  are  many  de- 
partures from  it  in  persons  who  are  perfectly  sound.  Such  "  physio- 
logical "  departures  may  be  mentioned;  a  slight  asymmetry  in  a 
gradually-acquired  spinal  curvature  or  a  deformity  of  the  ribs  self- 
established  ;  further,  a  peculiar  form  of  thorax,  where  the  upper  part 
is  somewhat  shallow,  but  the  lower  of  increasing  depth,  so  that  the 
lower  aperture  of  the  thorax  is  very  large ;  also  more  marked  angle  of 
Louis  (Braune) ;  again,  in  a  shorter  thorax,  a  more  acute  epigastric 
angle  may  sometimes  be  observed  in  healthy  persons  (hence,  also, 
without  signs  of  emphysema,  see  below)-  The  supra-clavicular  de- 
pressions are  often  both  deepened,  with  the  apices  of  the  lung  entirely 
normal  (unequal  deepening  of  them  is,  however,  very  suspicious  of 
tuberculosis,  see  below) ;  single  ribs,  more  frequently  the  second,  third, 
also  the  fourth,  sometimes  on  account  of  greater  curvature,  project 
more  in  front ;  on  the  other  hand,  the  lower  ribs  will  often  be  found 
pressed  into  the  side  and  from  there  flattened  forward,  and  other 
variations.  The  boundary  between  the  unsymmetrical  and  the  path- 
ological form  of  chest  is  much  confused ;  it  can  only  be  recognized  in 
the  individual  case  by  attention  to  the  location  and  function  of  the 
thoracic  organs. 

Normal  breathing  takes  place  in  this  wise :  inspiration  only  is 
active,  that  is,  is  accomplished  by  muscular  action ;  expiration,  on 
the  contrary,  is  produced  wholly  by  the  elasticity  of  the  lungs,  the 
weight  of  the  chest  wall,  and  the  pressure  of  the  abdominal  organs 
upon  the  diaphragm.  The  number  of  respirations  to  the  minute  in 
the  newborn  is  about  44  ;  at  five  years,  about  26  ;  from  the  twentieth 
year,  about  16  to  20.  It  is  very  easily  influenced  by  a  number  of  con- 
ditions :  in  sitting  and  standing  it  is  somewhat  higher  than  in  lying ; 
it  is  increased  by  bodily  activity  and  psychical  impressions.  There- 
fore, it  can  only  be  determined  during  perfect  quiet,  with  the  atten- 
tion withdrawn  from  the  examiner,  or  during  sleep.     For  counting 


EXAMIXATIOX  OF  THE  RESPIRATOR T  APPARATUS.  83 

it,  it  is  generally  most  advantageous  to  lay  the  hand  lightly  upon  the 
chest  (or  upon  the  epigastrium). 

The  breathing  is  generally  regular,  and  the  single  breaths  of  equal 
strength ;  but  under  the  influence  of  the  shghtest  psychical  disturbance 
it  easily  becomes  irregular  and  unequal.  Many  persons  of  sound 
health,  as  snorers  in  sleep,  often  breathe  irregularly  or  unequally 
deeply.  Breathing  is  either  exactly  or  very  nearly  symmetrical,  though 
the  left  side  frequently  inclines  to  breathe  a  trifle  stronger. 

The  inspiratory  enlargement  of  the  thorax  is  occasioned  by  the 
elevation  of  the  ribs  and  the  sternum,  and  the  simultaneous  drawino- 
of  the  former  upAvard  and  outward  (intercostales  extern!  and  interni 
muscles — '■^  costal  breathing'');  moreover,  by  the  contraction  of  the 
diaphragm,  and,  hence,  flattening  of  its  dome.  The  latter  movement, 
at  the  same  time,  draws  down  the  intestines,  and  so  with  every  inspira- 
tion the  whole  anterior  wall  of  the  abdomen  projects,  but  especially 
the  epigastrium  (diaphragmatic,  or  abdominal,  breathing).  The  com- 
bination of  costal  and  diaphragmatic  breathing  varies  in  the  two 
sexes  in  that  in  the  male  the  latter,  and  in  the  female  the  former, 
preponderates.  But  in  aged  females,  with  firm  thoracic  walls,  dia- 
phragmatic breathing  increases ;  while,  on  the  other  hand,  male  as 
well  as  female  children  incline  to  the  costal  type  of  breathing.  From 
this  it  seems  that  the  degree  of  flexibility  of  the  thorax  influences  the 
kind  of  breathing. 

In  the  costal  breathing  of  women,  even  in  quiet  respiration,  the 
scaleni  muscles  (elevators  of  the  first  and  second  ribs)  take  a  part ; 
w^hile  in  men  these  muscles  belong  to  the  auxiliary  muscles  of  respira- 
tion (see  below), 

2.  Pathological  Forms  of  Thorax. 

(a)  The  inflated  or  emphysematous  thorax.  This  refers  to  a 
chronic  symmetrical  expansion  in  all  directions,  conforming  somewhat 
to  the  form  of  the  chest  during  inspiration  (the  inspiratory  position). 
The  antero-posterior  (the  sterno-vertebral)  diameter  is  increased.  In 
many  cases  it  appears  as  if  the  thorax  became  enlarged,  especially  at 
about  the  height  of  the  middle  of  the  sternum,  making  a  barrel-shaped 
chest;  however,  this  may  be  entirely  wanting.  The  ribs  are  generally 
strong,  and  are  at  right  angles  to  the  sternum,  hence  the  epigastric 


34  SPECIAL  DIAGNOSIS. 

angle  is  larger  than  normal ;  the  thorax  is  generally  short.  Fre- 
quently the  angle  of  Louis  is  very  prominent. 

The  supra-clavicular  depressions  may  vary  very  much  ;  sometimes 
they  are  deepened,  again,  shallow  or  even  projecting  like  pillows  (the 
latter  condition  obtaining  in  emphysema  of  the  upper  part  of  the 
lungs).  The  lower  intercostal  spaces  are  sometimes  drawn  in  during 
inspiration. 

In  the  emphysematous  thorax  the  breathing  is  so  changed  that 
the  expiration  is  both  slower  and  imperfect  in  consequence  of  the 
diminished  elasticity  of  the  lungs ;  it  is  prolonged,  and,  in  marked 
emphysema,  it  is  assisted  by  muscular  action,  especially  by  the 
transversus  abdominis  and  the  quadratus  lumborum.  We  can  then 
plainly  see  the  abdominal  wall  energetically  flattened,  and  we  are 
directly  impressed  with  the  idea  that  the  thorax  is  forcibly  expanded. 
But  the  inspiration  is  also  altered  in  consequence  of  the  rigidity  of 
the  chest-wall ;  ordinary  costal  breathing  is  wanting ;  it  is  very  im- 
perfect ;  and  in  its  place  we  notice  that  the  front  of  the  chest,  as  a 
whole,  has  been  drawn  up  by  the  powerful  action  of  the  sterno-cleido- 
mastoidei  muscles.  Consequently,  in  emphysema  we  have  the  breathing 
rendered  difficult ;  in  severe  cases  it  may  become  so  to  a  high  degree 
(see  Dyspnoea). 

The  typical  emphysematous  thorax  points  almost  with  certainty  to 
emphysema,  and  hence  its  name ;  however,  we  must  guard  against 
the  mistake  of  calling  every  short  chest  an  emphysematous  one.  On 
the  contrary,  also,  we  not  infrequently  find  a  general  emphysema  of 
the  lungs  in  a  chest  that  has  no  trace  of  the  "  emphysematous  "  form. 
Active  expiration,  expiratory  dyspnoea,  is  much  more  characteristic 
than  the  form  of  the  thorax ;  besides  emphysema,  it  exists  in  no  other 
condition  except  certain  diseases  of  the  larynx  (see  Dyspnoea). 

(5)  The  paralytie  or  phthisical  thorax.  This  is  the  direct  opposite 
of  the  preceding :  it  is  flat,  especially  in  the  upper  part ;  is  often 
also  narrow ;  the  intercostal  spaces  are  wide ;  the  ribs  are  generally 
delicate,  are  sharply  inclined  downward  from  the  sternum,  and, 
hence,  must  be  bent  at  a  sharp  angle  again  in  order  to  come  back 
to  the  vertebrae.  This  sloping  from  the  sternum  makes  the  epigastric 
angle  very  sharp ;  the  chest,  as  a  whole,  chiefly  in  consequence  of  the 
course  of  the  ribs,  is  long.     The  angle  of  Louis  is  often  very  marked. 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.  85 

The  depressions  are  generally  deep.  The  shoulder-blades  frequently 
stand  out  like  wings. 

Quiet  breathing  may  be  almost  normal ;  by  exertion  it  is  generally 
immediately  very  much  increased  in  frequency  ;  it  is  shallow  ;  even 
in  women  the  costal  type  is  often  wanting,  especially  at  the  upper 
part  of  the  chest. 

This  form  of  chest  corresponds  with  that  of  tuberculosis.  A  well- 
marked  paralytic  thorax,  'except  where  phthisis  of  the  lungs  has  early 
developed,  is  very  infrequently  seen ;  but  yet  this  disease  occurs  very 
often  Avhere  the  phthisical  thorax  is  wholly  absent — indeed  with  an 
emphysematous  thorax.  In  a  paralytic  thorax,  with  phthisis  already 
developed,  by  means  of  the  latter  the  form  of  the  thorax  and  the 
breathing  will  become  essentially  and  variously  changed.  See  above 
under  {a)  and  below  under  {d). 

But  one  must  be  very  careful  not  to  conclude  that  a  thorax  narrow 
from  great  emaciation,  and  especially  one  that  appears  flat,  is  a 
paralytic  one.  For  example,  a  beginner  is  apt  to  find  that  a  patient 
convalescent  from  typhoid  fever  has  a  paralytic  chest.  Strictly 
speaking,  also,  every  plain  or  flattened  thorax  is  not  to  be  called  a 
paralytic  one.  Moreover,  emaciation  and  flattening  of  the  upper  parts 
of  the  chest,  in  cases  of  developed  phthisis,  frequently  render  the 
thorax  paralytic,  which  it  originally  was  not. 

(c)  One-sided  exjMJision  of  the  thorax,  a  relatively  infrequent 
affection,  occurs  in  disease,  or  functional  loss,  of  the  opposite  lung. 
The  dilated  side  is  then  the  seat  of  the  so-called  "  vicarious  em- 
physema "  of  the  lung.  This  is  distinguished  from  true  emphysema 
by  the  absence  of  expiratory  dyspnoea. 

The  dilated  side  is  much  more  frequently  the  diseased  one.  The 
widening  of  the  chest-cavity  is  more  plainly  seen  from  the  front  than 
from  behind.  Very  frequently  the  mamma  and  the  scapula  are 
further  removed  from  the  median  line  than  upon  the  normal  side. 
The  intercostal  spaces  are  level  or  are  projecting;  in  contrast  with 
this,  the  diseased  side  drags  after  the  other — that  is,  in  inspiration  it 
rises  later  and  less  than  the  sound  side,  and  it  may  even  not  rise  at 
all.  Hence,  the  spinal  column  is  sometimes  bent  toward  the  diseased 
side. 

Marked  expansion  is  met  with  in  pneumothorax  and  in  extensive 
pleuritic  exudation  ;  while  the  development  of  the  latter  usually  first 


gg  SPECIAL  DIAGNOSIS. 

manifests  itself  by  expansion  and  lagging  behind  at  the  posterioi-  and 
lower  part  of  the  chest.  A  very  slight  expansion  of  one  half  of  the 
chest  is^  moreover,  sometimes  seen  in  croupous  pneumonia  of  the 
"whole  of  the  affected  lung. 

Circumscribed  forward  expansion  of  the  chest  occurs  especially 
with  tumors  of  the  pleura,  and  is  sometimes  humped,  and,  again, 
uniform ;  empyema  which  inclines  to  breaking  through,  pushes  the 
affected  region  prominently  forward,  and,  at  the  same  time,  the  skin 
is  generally  oedematous.  Encapsulated  pleuritic  exudations  or  circum- 
scribed pneumothorax  seldom  cause  expansion,  yet  the  first  causes  a 
smoothing  out  of  the  neighboring  intercostal  spaces,  besides  lagging 
behind.  Local  projections,  moreover,  occur  not  infrequently  from 
inflammatory  affections  of  the  ribs  or  the  subcutaneous  cellular  tissue. 

Local  expansions  of  the  thorax  are  seen  in  cases  of  enlargement  of 
other  organs.  The  cardiac  region  may  be  bulged  out  in  enlargement 
of  the  heart  or  distention  of  the  pericardium  (see  under  Examination 
of  the  Heart) ;.  a  marked  enlargement  of  the  liver  may  press  out  the 
lower  ribs  on  the  right  side,  and  enlargement  of  the  spleen  on  the 
left ;  and  sometimes,  especially  in  children,  a  very  marked  expansion 
of  the  whole  lower  part  of  the  thorax,  an  enlargement  of  the  lower 
aperture  of  the  chest,  is  observed  in  cases  of  considerable  expansion 
of  the  whole,  or  the  upper  part,  of  the  abdomen  (meteorismus,  ascites, 
peritonitis,  tumors).  Then  the  upper  part  of  the  chest  seems  quite 
small  in  comparison  with  the  lower  part ;  the  whole  trunk  is,  hence, 
shaped  like  a  bee.  From  the  drawing  up  of  the  diaphragm  there 
results  interference  with  diaphragmatic  breathing,  and  generally  there 
is  severe  dyspnoea. 

It  is  very  important  to  remember  that  the  expansion  of  the  chest, 
especially  that  caused  by  pleuritic  exudation,  varies  with  the  flexibility 
of  the  thoracic  wall.  If  the  wall  is  soft,  as  is  the  case  with  children, 
the  expansion  is  very  pronounced;  if  rigid,  as  in  subjects  of  em- 
physema, sometimes  a  very  large  pleuritic  exudation  causes  no 
noticeable  expansion.  Therefore,  Avhile  we  expect  in  general  that  an 
extensive  pleuritic  exudation  will  manifest  itself  by  an  enlargement  of 
the  affected  side  of  the  chest,  yet,  where  the  walls  are  rigid,  we  must 
not  conclude  from  the  absence  of  expansion  that  there  is  no  exudation. 

{d)  Drawing-in  or  shrinking  of  one  side.  This  is  seen  more  or 
less  frequently  as  a  symmetrical  drawing-in  of  the  whole  side,  so  that 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.  g'J 

the  affected  side  is  altogether  smaller  than  the  other;  the  ribs  are 
close  together,  and  in  the  lower  part  they  may  even  overlap,  like 
shingles  on  a  roof.  The  shoulder  of  that  side  hangs  down ;  the  mamma 
and  scapula  are  nearer  the  median  line.  The  spinal  column  is  curved 
with  its  convexity  toward  the  healthy  side ;  hence,  the  whole  carriage 
is  affected.  There  is  diminished  breathing,  or  no  breathing  at  all,  on 
the  side  drawn  in ;  on  the  healthy  side,  there  develops  a  vicarious 
emphysema.  This  condition  is  observed  in  recovery  from  extensive 
pleuritic  exudations,  and  in  long-continued  contraction  of  the  lungs. 

In  pleurisy,  it  is  the  loss  of  elasticity  and  thickening  of  the  pleura, 
with  adhesions  of  pleural  surfaces,  in  shrinking  of  the  lungs,  and  the 
development  of  connective  tissue  in  the  lungs,  which  not  alone  hinder 
the  lungs  from  following  the  inspiratory  expansion  of  the  thorax,  but 
from  the  tendency  to  contract,  as  in  scars  of  the  skin,  draws  in  the 
chest-wall.  This  inward  traction,  however,  does  not  concern  the 
thorax  alone:  the  mediastinum,  heart,  and  diaphragm  are  pulled 
toward  the  sunken  side.  Hence,  there  is  displacement  of  the  heart 
toward  the  diseased  side,  and  the  diaphragm  is  high  in  the  chest. 

More  frequently  there  is  an  unequal  degree  or  a  partial  shrinking 
on  the  affected  side ;  with  it  also  is  always  connected  a  more  or  less 
marked  lagging.  It  is  most  frequently  observed  above  in  front,  here 
sometimes  noticeable  at  the  first  commencement  as  a  deepening  of  the 
supra-clavicular  depression  (an  important  symptom  of  contraction  of 
the  apex  of  the  lung  from  tuberculosis).  Again,  a  partial  drawing-in 
is  often  seen,  most  frequently  low  down  posteriorly,  after  the  disap- 
pearance of  a  small  pleuritic  exudation.  But  there  may  be  shrinking 
of  any  part  of  the  chest-wall,  as  after  gangrene  and  abscesses  of  the 
lungs. 

One  must  be  careful  not  to  confound  a  deformity  of  chest  from 
disease  of  the  thoracic  organs  with  deformities  that  are  dependent  on 
a  primary  bending  of  the  spine  and  thorax.  Concerning  these,  see 
the  following  section. 

A  repaired  fracture  of  the  ribs  may  also  cause  deformity ;  a  fracture 
of  the  clavicle  which  has  healed  with  an  angle  forward  may  deepen 
the  supra-  and  infra-clavicular  depressions,  and  so  deceive  one ;  one- 
sided defect  or  atrophy  of  the  pectoralis  major,  of  course,  flattens  that 
side.  All  of  these  cases  may  be  excluded  by  a  more  careful  examina- 
tion. 


gg  SPECIAL  DIAGNOSIS. 

ie)  Expansion  or  retraction  of  the  chest  hy  primary  deformity  of  the 
skeleton.  Kyphosis,  or  bending  backward,  and  scoliosis,  the  bending 
sidewise  of  the  spine,  but,  still  more,  the  combination  of  both,  kypho- 
scoUosis,  occasion  sometimes  deformities  of  the  chest  that  are  enormous. 
Most  frequently  one  side  is  smaller  in  front,  while  the  other  side 
appears  as  if  enlarged ;  and  the  picture  of  one-sided  contraction  of 
pleura  or  lung  is  more  complete  from  the  dragging-after  of  the  smaller 
side.  In  consequence  of  a  peculiar  twist  of  the  spine  and  its  effect 
upon  the  course  of  the  ribs,  the  back  is  generally  very  crooked.  This 
is  spokert  of  more  particularly  in  works  upon  surgery.  Whether 
we  have  to  deal  with  a  primary  deformity  of  the  chest  or  with  a 
contraction  of  the  lung  or  pleura  is  generally  made  clear  by  the  ex- 
amination of  the  spine ;  in  rare  cases,  however,  this,  and  even  the 
minutest  examination  of  the  thoracic  organs,  does  not  give  a  positive 
diagnosis.  Moreover,  the  thoracic  organs  are  almost  always  much 
displaced ;  the  lungs  are  in  part  functionally  very  much  disturbed. 
These  patients  have  short  breath  on  the  least  exertion  ;  and  in  case  of 
disease  of  the  chest  organs,  especially  in  acute  infectious  diseases,  are 
more  in  danger  than  others.  The  distinction  of  the  different  kinds  of 
spinal  curvature  and  their  origin  belongs  to  surgery. 

RhacMtis  is  frequently  the  cause  of  such  deformities,  but  it  may 
also  cause  all  other  possible  bendings  of  the  chest.  Of  these  espe- 
cially characteristic  are  :  1.  The  rhachitie  chest,  a  thickening  of  the 
point  of  transition  from  the  cartilage  to  the  bony  ribs.  The  several 
prominences  arising  from  it  form  on  both  sides  of  the  sternum  a  line 
passing  as  aa  arch  outward  and  downward.  2.  The  pigeon-chest. 
The  chest  seems  to  be  compressed  sidewise  and  pressed  forward.  The 
ribs  run  sharply  backward  from  the  front,  so  that  the  sternum  stands 
forward  like  the  keel  of  a  ship,  the  sterno-vertebral  measurement 
being  much  increased.  3.  A  circular  draioing4n  in  the  neighbor- 
hood of  the  costal  attachment  of  the  diaphragm.  The  ribs,  as  is  well 
known,  form  a  fixed  point  for  the  diaphragm  ;  if,  as  in  rhachitis,  the 
chest  is  abnormally  yielding,  it  is  drawn  inward  by  the  contraction  of 
the  diaphragm,  and  this  especially  is  the  case  if  there  is  increased 
action  of  the  diaphragm — that  is,  if  from  any  cause  there  is  difficulty 
of  breathing. 

Funnel-breast  (Fig.  15).  This  deformity  consists  in  a  sinking-in 
of  the  sternum,  especially  of  the  lower  portion  of  it ;    it  may  be 


EX  A  MIXA  TION  OF  THE  R  ESP  IRA  TOR  Y  A  PPA  RA  TUS.  g  9 

very  considerable  (as  much  as  seven  cm.).  The  aifection  is  generally 
congenital,  and,  according  to  our  experience,  in  very  marked  cases  it 
may  prove  a  hindrance  to  respiration.  Shoemakers' -bf-east  exhibits 
a  sort  of  acquired  funnel-breast,  caused  by  pressure  of  tools  against 
the  lower  part  of  the  sternum  and  the  xiphoid  cartilage ;  the  depres- 
sion never  becomes  very  great,  and  involves  only  the  cartilage ;  it ' 
has  no  pathological  significance. 

Fig.  15. 


J'unnel-breast.     (Ebstein.) 

According  to  recent  experience,  the  funnel-breast  sometimes  is 
observed  in  several  branches  of  a  family.  In  individual  cases  it 
occurs  as  a  sign  of  degeneration,  with  other  errors  of  development,  or 
associated  with  neuropathic  or  psychopathic  disease  or  hereditary 
taint. 

3.  Anomalies  of  JRespiration. 

In  the  preceding  section  the  anomalies  of  breathing  which  accom- 
pany thie  several  pathological  forms  of  thorax  have  been  briefly 
referred  to.      But  these  require  a  further  separate  description.     In 


90  SPECIAL  DIAGNOSIS. 

giving  this  it  will  not  be  possible  to  avoid  a  partial  repetition  of  what 
has  already  been  said. 

{a)  Anomalies  of  the  manner  of  breathing.  The  type  of 
breathing  which,  as  has  been  mentioned  above,  in  the  normal  human 
being  is  typically  different  in  the  two  sexes,  and  is  denominated  costal 
and  costo-abdominal,  may  be  influenced  by  a  number  of  different 
pathological  conditions. 

1.  The  activity  of  the  diaphragm,  from  some  cause  or  other,  may 
be  restricted  or  entirely  stopped  ;  it  may  then  be  replaced  by  increased 
thoracic  breathing ;  this  causes  the  costal  type  peculiar  to  women  to 
be  still  more  prominent,  while  the  male  type  is  reversed ;  instead  of 
the  abdominal  predominating,  the  costal  becomes  predominant  or 
entirely  prevails — that  is,  may  take  on  the  female  type 

Such  a  restriction  or  prevention  of  the  action  of  the  diaphragm  is 
occasioned  by  pain,  or  mechanical  restraint,  or  by  Aveakness  or  paralysis 
of  the  diaphragm.  Such  is  the  action  of  all  inflammations  of  the 
abdominal  or  pleural  cavities  in  case  they  involve  the  corresponding 
serous  covering  of  the  diaphragm,  markedly  impairing  diaphragmatic 
breathing ;  they  often  act  so  because  they  are  painful ;  but  also  some- 
times, especially  in  inflammation  of  the  diaphragmatic  peritoneum, 
actual  paralysis  of  the  diaphragm  quickly  develops,  which  is  recog- 
nized by  the  entire  disappearance  of  abdominal  breathing  (see  above, 
p.  83).  This  takes  place  quite  commonly  in  diffuse  peritonitis ;  it  is, 
however,  also  sometimes  the  only  symptom  of  a  beginning  local  "sub- 
phrenic" peritonitis.  Marked  distention  of  the  abdomen  by  tumors, 
fluid,  and  accumulations  of  gas  in  the  intestines,  hinder  diaphragmatic 
breathing  in  a  high  degree.  Finally,  there  occurs  paralysis  of  the 
diaphragm  in  organic  diseases  of  the  nervous  system  (bulbar  paralysis ; 
neuritis  of  the  phrenic  nerve  in  the  various  forms  of  multiple  neuritis), 
as  well  as  a  manifestation  of  functional  neurosis  (hysteria). 

The  action  of  the  diaphragm  is  recognized,  as  has  frequently  been 
mentioned,  by  the  protrusion  of  the  epigastrium  during  inspiration. 
Of  course,  this  does  not  take  place  when  there  is  no  contraction.  In 
complete  paralysis  the  diaphragm  is  sometimes  even  completely  sucked 
into  the  thorax ;  in  hysteria,  during  inspiration,  the  epigastrium 
sometimes  sinks  in  extraordinarily  deep.  One-sided  failure  of  action 
of  the  diaphragm  may  also  occasionally  be  made  out.    (See  Palpation.) 

2.  But  sometimes,  also,  hindered  thoracic  breathing  may  be  replaced 


EX  A  MINA  TIO  N  OF  THE  RESPIRA  TORY  A  PPARA  TVS.  9 1 

by  increased  diaphragmatic  breathing ;  hence,  in  such  a  case,  if  the 
patient  is  a  female,  the  type  of  breathing  is  changed — that  is,  ab- 
dominal breathing  predominates  instead  of  costal. 

Therefore,  in  very  rigid  thorax  (emphysema),  sometimes  also  in 
women,  diaphragmatic  breathing  predominates.  Here  belong  paralysis 
of  the  muscles  of  inspiration  (bulbar  paralysis),  and  myositis  ossificans 
(rare),  since  it  causes  a  rigid  condition  of  the  thorax.  A  peculiar 
disease  of  the  skin,  schleroderma,  may,  if  located  upon  the  thorax, 
also  entirely  abolish  thoracic  breathing. 

It  has  been  shown  above,  under  emphysematous  thorax,  how,  in 
lieu  of  the  peculiar  costal  breathing,  this  may  in  part  be  replaced  by 
the  movement  of  the  thorax  as  a  whole  by  the  (auxiliary)  muscles — 
the  sterno-cleido-mastoidei. 

3.  Asymmetry  of  breathing,  which  is  occasioned  as  follows :  the 
whole  side,  or  the  upper  or  lower  part  of  one  side,  either  (very  rarely 
plainly)  expands  somewhat  later  than  the  opposite  side,  or  (most  fre- 
quently) expands  less  strongly  or  not  at  all — which  condition  has 
already  been  mentioned  several  times. 

Such  a  lagging  may  be  caused  by  a  unilateral  painful  affection  of 
any  kind ;  moreover,  by  all  diseases  of  the  thoracic  organs  which 
interfere  with  respiration  upon  one  side.  This  "lagging  behind"  is 
a  valuable  symptom,  especially  in  phthisis  (lagging  in  the  infra- 
clavicular depression),  also  in  the  beginning  of  pneumonia  and 
pleurisy^  when  other  symptoms  are  wanting.  (See  Palpation  of  the 
Thorax.) 

(h)  Anomalies  of  breathing  as  regauds  frequency  and 
RHYTHM.  Diminished  frequency  of  breathing  may  take  place  in  all 
severe  diseases  of  the  brain  and  its  meninges,  hence  in  large  hemor- 
rhages, tumors,  etc.,  and  in  all  forms  of  meningitis;  thereby  exists 
always  more  or  less  dulness  of  intellect ;  the  slowness  of  breathing 
may  sometimes  pass  into  the  Cheyne-Stokes  respiration  (see  below). 
Further,  in  acute  infectious  diseases,  with  marked  mental  dulness, 
the  respiration  may  be  slower ;  finally,  it  is  generally  so  in  the  death 
agony. 

A  very  important  form  of  diminished  frequency  of  respiration  is 
observed  with  stenosis  of  the  upper  air-passage ;  this  belongs  in  the 
section  on  Dyspnoea.     Increased  frequency  of  respiration  as  a  patho- 


92  SPECIAL  DIAGNOSIS. 

logical  manifestation  belongs,  without  exception,  to  a  large  group, 
which  will  also  be  discussed  in  the  next  section. 

It  has  already  been  mentioned  that  we  meet  with  temporary  irregu- 
larity of  breathing  in  healthy  persons.  It  is  of  pathological,  and 
generally  of  grave,  import  in  all  cases  of  marked  mental  dulness  (as 
in  apoplectic,  urgemic,  and  the  coma  of  severe  typhus),  and  very 
especially  in  the  death-agony. 

The  so-called  Cheyne-Stokes  breathing  is  a  very  peculiar  form  of 
breathing,  which  is  periodically  repeated.  It  is  unequal  and  arhyth- 
mic:  in  typical  cases  one  or  two  quite  superficial  breaths  are  followed 
by  four  or  five  that  are  successively  deeper  and  more  noisy,  with  strong 
action  and  snorting  or  snoring,  sometimes  also  a  sort  of  deep  sighing ; 
then  the  resnirations  are  ag-ain  regular,  become  also  sometimes  some- 
what  slower ;  the  fourth  or  fifth  from  the  acme  is  even  hardly  notice- 
able ;  then  follows  a  pause  of  variable  length  without  any  breath 
("  apnoea  ") ;  this  may  last  as  much  as  a  minute;  then  the  course  as 
above  described  is  repeated.  Frequently,  also,  there  is  a  regularly 
recurring  apnoea  alternating  with  ordinary  deep  breaths. 

Very  remarkable  cases,  of  which  I  have  seen  a  few,  but  of  which 
others  have  observed  many,  are  those  in  which  patients,  ordinarily 
unconscious,  become  conscious  regularly  with  each  return  of  the  deep 
breathing ;  they  open  the  eyes,  raise  the  head  a  little,  and  may  pos- 
sibly even  ask  questions ;  but,  with  the  return  of  the  apnoea,  the 
patient  again  sinks  into  unconsciousness.  In  individual  cases  this 
form  of  breathing  occurs  with  patients  'who  are  almost  entirely 
conscious. 

The  Cheyne-Stokes  respiration  is  observed  in  all  forms  of  meningitis 
and  in  hemorrhages,  tumors,  etc.,  of  the  brain ;  likewise,  in  heart- 
failure  in  consequence  of  heart-disease  of  whatever  sort,  but  especially 
from  fatty  heart  (Stokes),  in  uraemia  (uraemic  coma) ;  finally,  in 
poisoning  by  opium  or  morphine.  Besides,  it  may  occur  occasionally 
in  any  deep  coma. 

It  is  very  difficult  to  explain  the  significance  of  this  phenomenon, 
in  that  it  is  not  always  a  fatal  one.  We  have  seen  it  frequently 
without  fatal  result  in  uraemia,  also  in  one  case  of  apoplexia  cerebri, 
and  once  in  a  case  of  acute  diifuse  peritonitis  of  the  vermiform  ap- 
pendix.    In  heart  diseases  it  seems  at  any  rate  to  indicate  approaching 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.  93 

death.      It  may  last  Lours  and  days  ;  it  is  said  to  have  even  been 
observed  to  continue  for  ahmost  seven  months. 

It  is,  without  question,  dependent  upon  a  disturbance  of  the  function 
of  the  respiratory  centre  in  the  medulla  oblongata.  But  we  are  in 
want  of  any  exact  description  of  the  nature  of  this  disturbance. 
A  simple  diminution  of  the  irritability  of  these  ganglion-cells  cer- 
tainly must,  from  the  blood  containing  CO2,  have  eventually,  as  a  less 
frequent  result,  deep  or  superficial  (possibly  irregular)  breathing,  as  is 
seen  in  the  death-agony.  To  ascribe  a  different  degree  of  irritability 
to  particular  cells  or  groups  of  cells,  as  some  have  done,  is  at  least  a 
great  refinement.  In  short,  we  have  no  clear  explanation  of  this 
phenomenon.  Moreover,  the  peculiar  change  of  consciousness,  and 
the  other  manifestations  that  have  sometimes  been  observed  to  accom- 
pany it  (the  contracted  pupils  in  apnoea,  jerking  of  the  muscles  at  the 
close  of  the  apnoea),  do  not  throw  any  clear  light  upon  the  subject.^ 

(a)  Difficult  breathing,  dyspncea.  We  have  to  designate  that 
form  of  dyspnoea  as  physiological  which  results  when  the  respiratory 
centre  is  supplied  with  blood  which  contains  less  than  the  normal 
quantity  of  0,  or  an  increased  amount  of  COg.  The  pathologist  and 
the  clinician  speak  of  dyspnoea  if  the  respiration  is  labored,  whether 
the  number  of  respirations  be  normal,  or  prolonged,  or  more  frequent. 
Finally,  in  all  cases  of  increased  respiration,  if  rapid  and  labored 
breathing  are  combined,  dyspnoea  is  caused  by  all  those  conditions 
that  interfere  in  any  way  with  the  exchange  of  gases  in  the  lungs  (see 
Tinder  Cyanosis).  But  there  is  another  condition  which  manifests 
itself  by  an  increased  formation  and  giving  off  of  COj;  that  condition 
is  fever. 

Labored  respiration  with  normal  or  diminished  frequency  takes 
place  in  stenosis  of  the  upper  air- passage — that  is,  of  the  larynx  and 
trachea.  Intra-tracheal  tumors,  foreign  bodies,  inflammations  (espe- 
cially croup),  cicatricial  strictures  (generally  syphilitic),  granulations, 
also,  compression  from  without,  and  lastly  paralyses  of  certain  laryngeal 
muscles  (see  under  Inspiratory  Dyspnoea),  produce  narrowing  of  the 
air-passage. 

1  Recently,  Mosso  points  out  that  there  is  a  like  oscillation  in  the  sleep  of  healthy- 
persons,  and  explains  it  by  the  assumption  of  a  "  breathing  luxus"  ;  he  considers  the 
Cheyne-Stokes  phenomenon  simply  as  a  pathological  example  of  the  same  phenomenonj 
but  the  condition  is  not  explained  by  this. 


94  SPECIAL  DIAGNOSIS. 

Strictly  speaking,  this  form  of  dyspnoea  often  occurs  in  diseases  of 
the  brain  (also  see  above,  page  91).  At  the  acme  of  respiration  in 
Cheyne-Stokes  breathing  we  must  speak,  too,  of  there  being  dyspnoea. 

Increased  Frequency  of  Respiration  Occurs  : 

(a)  In  fever.  Here  it  is  often  simply  increased  frequency,  the 
breaths  being  deeper,  but  sometimes,  also,  we  notice  that  they  become 
somewhat  labored  (without  its  being  a  question  of  complication  of  the 
thoracic  organs).  The  amount  of  quickening  of  the  respiration  varies 
very  much,  according  to  the  nature  of  the  disease  and  with  the  indi- 
vidual. Nervous  persons  often  breathe  remarkably  rapidly  in  fever ; 
with  children,  respirations  as  high  as  sixty  or  more  to  the  minute 
have  often  been  observed.  Nevertheless,  in  fever  every  case  of  marked 
increase  in  frequency  of  breathing  must  lead  to  an  especially  careful 
examination  of  the  thoracic  organs.  The  cause  of  fever- dyspnoea  is, 
moreover,  not  alone  the  increased  formation  of  CO^,  but  is  also  the 
result  of  the  irritation  of  the  respiratory  centre  by  the  warmer  blood. 

Fever-dyspnoea  may  be  increased  by  association  with  that  caused 
by  diseases  of  the  respiratory  apparatus. 

(&)  In  all  conditions  that  are  connected  with  pain  in  breathing. 
Here  belong  all  diseases  of  the  pleura  or  the  lungs  in  connection  with 
the  pleura  (especially  croupous  pneumonia),  inflammatory  affections 
of  the  diaphragm  (trichinosis),  of  the  peritoneum  (especially  the 
diaphragmatic  peritoneum),  fracture  of  ribs,  and  severe  rheumatism 
of  the  muscles  of  the  thorax. 

Rightly  to  explain  this  form  of  dyspnoea  is  often  of  the  greatest 
therapeutic  value ;  it  may  sometimes  (not  always)  be  relieved  by  a 
narcotic. 

(c)  In  diseases  of  the  bronchial  tubes,  which  narrow  or  close  the 
tubes  by  the  secretion  or  exudation.  Here  belong  all  forms  of  bron- 
chitis, and  also  bronchial  asthma.  In  the  latter  disease  there  is  much 
less  swelling  and  exudation  than  from  bronchial  spasm  of  neurotic 
origin,  which  chiefly  causes  the  dyspnoea.  No  doubt  spasm  of  the 
diaphragm  is  associated  with  this  sometimes,  which  causes  a  prolonged 
inspiratory  expansion  of  the  lungs,  and,  of  course,  this  increases  the 
dyspnoea. 

Where  there  is  bronchial  asthma  and  croupous  bronchitis  in  addi- 
tion to  laryngeal  croup,  there  is  generally  very  severe  dyspnoea  with 
quicker  and  very  forced  respiration.     Simple  catarrh  of  the  bronchial 


JilXAMIXA  TIOX  OF  THE  RESPIRA  TOR  Y  A PPA RA  TUS.  9  5 

tubes  generally  leads  to  quickening  of  the  respiration  without  the  breaths 
being  deeper ;  for  a  complete  closure  of  the  bronchial  tubes  cuts  off  a 
large  section  of  lung,  and  so  breathing  is  entirely  lost  in  this  section, 
as  in  capillary  bronchitis,  especially  in  children.  The  consideration 
of  this  condition  properly  belongs  to  the  next  section,  in  that  it  results 
in  the  lung-tissue  itself  becoming  diseased. 

((?)  In  all  conditions  in  which  the  breathing  surface  of  the  lungs  is 
diminished  or  the  volumetric  variation  of  the  lungs,  which  is  necessary 
for  respiration,  is  disturbed.     These  are : 

All  diseases  of  the  lungs :  the  different  forms  of  pneumonia,  oedema 
of  the  lungs,  infarction,  tuberculosis,  emphysema  (this  not  only  on 
account  of  the  diminished  breathing  surface,  but  also  the  loss  of 
elasticity,  and  hence  diminished  contraction  of  the  lungs  during 
expiration) ;  the  different  forms  of  pleurisy  with  exudation,  pneumo- 
thorax ;  tumors  in  the  chest-cavity  which  diminish  its  capacity ;  abdom- 
inal affections  which  push  up  the  diaphragm  ;  marked  kyphoscoliosis 
with  the  resulting  deformity  of  the  chest  and  consequent  unfavorable 
condition  for  breathing ;  paralysis  of  the  muscles  of  respiration  ;  and 
also  tonic  and  clonic  spasm  of  the  muscles  of  the  chest,  as  in  tetanus 
and  epilepsy,  which  may  occasion  the  most  severe  dyspnoea. 

As  is  evident,  these  diseases  differ  widely  from  one  another.  Those 
that  diminish  the  chest-cavity,  if  they  are  inconsiderable,  sometimes 
merely  restrict  the  inspiratory  expansion  of  the  chest,  and  so  affect 
the  lungs ;  but,  if  they  are  marked,  then  they  directly  compress  the 
lungs,  and  hence  diminish  their  breathing-surface. 

It  has  been  already  stated  that  in  a  number  of  these  conditions  the 
need  of  oxygen  may  be  met  by  a  substitution  of  diaphragmatic 
breathing  in  place  of  the  diminished  costal  breathing,  and  vice  versa. 
It  is,  of  course,  very  calamitous  when  there  is  a  combination  of  several 
causes  of  dyspnoea,  as,  for  example,  when  a  subject  of  kypho-scoliosis 
has  an  abdominal  affection  which  presses  up  the  diaphragm,  or  has 
inflammation  of  ^^^  lungs. 

Accommodation,  adaptation,  plays  an  important  part  in  many 
chronic  diseases  which  occasion  dyspnoea.  This  becomes  most 
strikingly  evident  if  we  compare  the  terrible  dyspnoea  of  beginning 
pneumo-thorax  with  the  relatively  comfortable  condition  of  patients 
who  have  continually  at  their  disposal  for  breathing  only  one 
lung,  or  even  only  a  part  of  a  lung.     In  many  of  these  cases  it  is 


96  SPECIAL  DIAGNOSIS. 

easy  to  understand  this  accommodation ;  chronic  cases,  especially 
phthisical  patients,  who  here  come  prominently  into  view,  are  generally 
anaemic,  and  therefore  require,  at  least  when  quiet,  only  a  very  small 
interchange  of  gases  in  the  lungs ;  but  every  effort  at  muscular  exer- 
tion immediately  causes  dyspnoea.  On  the  other  hand,  "  lung  dys- 
pnoea" is  generally  considerably  increased  in  one  who  has  an  acute 
disease,  by  the  fever.  Likewise,  there  are  cases  where  we  cannot 
dispense  with  the  idea,  which  formerly  was  not  clear,  of  an  "accom- 
modation." 

Dyspnoea  further  occurs : 

(e)  In  diseases  of  the  heart  which  cause  stasis  of  blood  in  the  lung 
circulation.  These  are  mitral  insufficiency  or  stenosis  of  the  left 
auriculo-ventricular  opening;  also  heart-failure,  which  may  occur  in 
all  diseases  of  the  heart. 

It  is  evident  that  slowing  of  the  capillary  circulation  of  the  lungs 
diminishes  the  interchange  of  gases  in  the  whole  quantity  of  the 
blood ;  but  generally  we  have,  beside  this,  a  diminution  of  the  alveolar 
lumen,  from  the  capillaries  being  swollen,  especially  in  the  so-called 
brown  induration  of  the  lungs. 

Increased  and  forced  resjnration.  Forced  respiration  may  at  any 
time  be  associated  with  rapid  breathing  by  increase  of  dyspnoea.  The 
only  exceptions  to  this  are  those  cases  that  arise  from  pain  and 
paralysis,  both  from  reasons  that  are  easily  intelligible. 

Mechanism  of  forced^  respiration.  This  is,  in  the  most  charac- 
teristic way,  different  from  normal  breathing,  namely,  that  while  the 
muscles  of  ordinary  inspiration  and  the  mechanical  conditions  of  ex- 
piration no  longer  suffice,  inspiration  and  expiration  are  assisted  by 
the  action  of  the  auxiliary  muscles  of  respiration. 

The  auxiliary  muscles  of  inspiration  are :  the  scaleni  muscles  in  the 
male  (in  the  female  they  act  even  in  quiet  breathing),  as  elevators  of 
the  two  first  ribs ;  the  sterno-mastoidei  draw  up  the  sternum  when  the 
head  is  fixed;  the  pectoralis  major  and  minor,  thelevatores  costarum, 
the  serratus  post,  super.,  all  of  which  act  as  elevators  of  the  ribs,  the  first 
named  when  the  upper  arms  are  fixed.  In  more  severe  dyspnoea  the 
trapezius,  the  levator  scapulae,  the  rhomboideus,  are  brought  into 
action  to  elevate  the  scapula;  in  severest  dyspnoea  the  extensors  of 
the  neck  assist  also,  and  then  we  notice  the  expansion  of  the  alae 
nasi  (see  under  Nose) ;  when  the  mouth  is  open  the  soft  palate  is 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.  97 

seen  to  be  drawn  up  during  inspiration ;  and,  finally,  even  those  mus 
cles  that  dilate  the  mouth  and  depress  the  larynx  may  be  brought 
into  action. 

The  muscles  have  very  varying  degrees  of  importance,  the  greatest 
being  the  work  of  lifting  up  the  ribs,  the  sternum,  and  the  shoulders. 
The  expansion  of  the  al^e  nasi  as  a  symptom  is  not  unimportant,  but 
really  does  not  at  all  assist  in  breathing. 

In  expiration  the  following  muscles  act  in  assisting  respiration  :  Of 
first  importance  are  the  broad  muscles  of  the  abdomen,  especially  the 
transversus,  which  compress  the  abdominal  contents,  thus  pressing  up 
the  diaphragm ;  further,  the  quadratus  lumborum  and  serratus  post, 
infer.,  which  draw  down  the  lower  ribs. 

It  is  easy  to  distinguish  the  moderate  drawing-in  of  the  thorax  and 
epigastrium  which  occurs  in  normal  passive  expiration  from  the  active 
expiration  of  dyspnoea,  by  the  energy  of  the  act  in  consequence  of 
muscular  contraction.  Moreover,  the  contraction  of  the  broad  mus- 
cles of  the  abdomen  is  plainly  to  be  seen.   • 

Patients  with  forced  respiration  exhibit  still  other  appearances 
which  partly  stand  in  direct  relation  to  the  increased  energy  of  the 
breathing. 

That  the  thorax  may  be  entirely  easy  and  that  the  auxiliary  mus- 
cles may  be  able  to  act  better,  patients  prefer  the  upright  posture  to 
lying  down  (Orthopnoea,  p.  32) — indeed,  in  very  severe  dyspnoea,  they 
may  not  be  able  to  lie  down  at  all ;  the  arms  are  fixed  in  order  that 
the  upper  arms  and  shoulders  may  furnish  a  fixed  point  for  the 
auxiliary  muscles ;  and,  in  order  that  the  sterno-cleido-mastoidei  may 
act  most  efficiently  in  assisting  respiration,  the  neck  is  stretched  and 
the  face  somewhat  elevated. 

Not  infrequently  the  breathing  is  audible ;  in  forced  respiration,  it 
is  panting,  groaning.  In  stenosis  of  the  larynx  or  trachea  we  hear 
the  before-mentioned  hissing — stridor  laryngeus  vel  trachealis.  The 
voice  is  weak,  often  suppressed  ;  the  patient  speaks  with  short,  un- 
natural pauses ;  broken  speech. 

Here  belongs  the  so-called  inspiratory  "  drawing-in."  Even  in 
healthy  people  we  sometimes  notice  with  forced  respiration  that  the 
lower  intercostal  spaces  in  the  beginning  of  inspiration  sink  in  some- 
what (a  simple  flattening-out  takes  place  from  the  contraction  of  the 
intercostal  muscles).     Drawing-in  that  is  more  marked  and  is  pro- 

7 


98  SPECIAL  DIAGNOSIS. 

longed  during  the  whole  of  inspiration,  under  all  circumstances  is 
pathological ;  with  very  yielding  thorax  (children),  even  the  ribs  and 
the  lower  part  of  the  sternum  may  share  in  the  condition.  It  shows 
that  the  lungs  do  not  follow  the  motion  of  the  thorax — that,  there- 
fore, the  air  is  prevented  from  entering  the  alveoli. 

Hence,  all  forms  of  stenosis  of  the  larynx  (especially  frequent  with 
croup)  and  of  the  trachea  (likewise  both  bronchi)  cause  inspiratory 
drawing-in  of  both  sides,  most  markedly  of  the  lower  part  of  the 
sternum,  the  lower  ribs,  and  intercostal  spaces  ;  if  the  stenosis  is  very 
marked,  the  condition  is  extended  to  the  upper  ribs  and  intercostal 
spaces,  as  far  as  the  jugular  and  supra-clavicular  spaces.  Stenosis  of 
a  bronchus  causes  inspiratory  drawing-in  of  one  side  when  the 
breathing  has  a  certain  degree  of  force,  beside  "lagging"  of  the 
affected  side.  Bronchitis  of  the  smaller  tubes  (especially  in  children) 
may  occasion  inspiratory  drawing-in  in  a  more  circumscribed  way,  as 
only  the  lower  part  upon  one  side.  But  we  may  also  sometimes  see 
an  extended,  very  marked  drawing-in  with  extensive  capillary  bron- 
chitis (with  atelectasis,  broncho-pneumonia)  in  children. 

There  are  two  reasons  why  stenosis  of  the  upper  air-passage  causes 
the  drawing-in  to  be  greatest  at  the  lower  part  of  the  chest,  and  which 
may  also  affect  the  ribs  of  this  part :  first,  the  air  entering  the  lungs, 
reaches  the  lowest  part,  as  being  the  furthest  removed,  last ;  secondly, 
if  the  thorax  is  yielding,  it  is  drawn  in  by  the  contraction  of  the  dia- 
phragm ;  for  if  the  diaphragm  cannot  descend  when  it  contracts, 
since  the  lung  does  not  follow  it,  then  the  dome  of  the  diaphragm 
becomes  a  fixed  point,  and  the  thorax  in  the  neighborhood  of  the 
insertion  of  the  diaphragm  is  drawn  inward  and  upward. 

Also,  expiratory  bulging  sometimes  takes  place  in  the  supra- 
clavicular depression,  especially  in  marked  emphysema  of  the  upper 
part  of  the  lung,  as,  for  example,  after  whooping-cough  (see  p.  76) ; 
or  in  the  upper  intercostal  spaces,  when  large  cavities  are  adherent  to 
the  chest-wair,  as  in  pulmonary  phthisis.  With  this  appearance  there 
is  a  strongly-marked  pressure  in  the  thorax  ;  hence  it  is  observed  only 
in  very  forced  expiration,  and  especially  in  strained  coughing. 

Very  frequently  we  find  in  cases  of  lung-cavities  with  expiratory 
bulging — especially  frequent  in  the  second  intercostal  space — the 
affected  intercostal  muscles  very  much  shrunken,  sometimes  fatty 
degeneration  of  them. 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.  99 

Finally,  the  picture  of  such  an  unfortunate  will  be  completed  by 
the  expression  of  subjective  anxiety;  sometimes  of  the  most  fearful 
agony  ;  by  the  peculiar  expression  of  the  eyes,  the  consequence  of  the 
dilatation  of  the  pupils  which  always  exists  in  dyspnoea  (see  Nervous 
System) ;  lastly,  by  the  cyanosis  and  frequent  cold  sweat  [q.  v.). 

According  as  inspiration  or  expiration,  or  both,  are  difficult,  or  the 
auxiliary  muscles  of  respiration  are  brought  into  action,  we  distinguish 
an  inspirator^/  (pure  or  preponderating),  an  expiratory  (pure  or  pre- 
ponderating), a  mixed,  dyspnoea. 

Purely  inspiratory  dyspnoea  exists  with  paralysis  of  the  posterior 
cricoarytenoid  muscles  (dilators  of  the  glottis);  here  expiration  is 
free,  since  the  escaping  current  of  air  presses  the  vocal  bands  apart ; 
on  the  other  hand,  the  in-rushing  air  brings  them,  like  valves,  in 
contact,  and  hence  inspiration  may  be  hindered  even  to  threatened 
suffocation.  Tumors  and  foreign  bodies  may,  moreover,  be  sometimes 
so  located  as,  by  valve-like  closure,  almost  completely  to  preclude 
inspiration.  Further,  inspiratory  dyspnoea  occurs  with  increased 
activity  of  other  muscles  when  certain  respiratory  muscles  are  para- 
lyzed (as,  for  example,  in  paralysis  of  the  diaphragm,  increased 
thoracic  breathing  is  accomplished  by  the  auxiliary  muscles). 

Purely  expiratory  dyspnoea  is  observed  with  movable  tumors 
situated  below  the  glottis  ;  the  out-going  air  pushes  them  against  the 
rima  glottidis,  but  in  expiration  they  are  drawn  to  one  side. 

Moreover,  a  preponderating  expiratory  dyspnoea  is  peculiar  to 
bronchial  asthma  (in  addition  to  the  always  present  inspiratory). 
Probably  we  correctly  assume  that  the  smallest  tubes,  spasmodically 
narrowed,  are  still  more  compressed  by  the  pressure  in  the  thorax 
during  expiration. 

The  disease  that  most  frequently  causes  expiratory  dyspnoea  is 
emphysema  of  the  substance  of  the  lungs  ;  the  diminished  power  of 
expiration  is  chiefly  from  the  loss  of  elasticity  of  the  lung-tissue,  the 
contracting  force  of  the  lungs  ;  generally  there  is,  besides,  diminished 
thoracic  breathing — since,  if  the  thorax  is  too  rigid  to  expand  during 
inspiration,  then  it  is  also  not  conti-acted,  either  by  virtue  of  its  own 
elasticity  or  the  traction  of  the  lungs. 

Bronchial  asthma  of  long  duration  always  causes  emphysema  of 
the  lungs ;  then,  of  course,  there  is  a  twofold  cause  of  expiratory 
dyspnoea. 


1(30  SPECIAL  DIAGNOSIS. 

In  genuine  emphysema  of  the  lungs  there  is  always  also  well-marked 
inspiratory  dyspnoea,  on  account  of  the  atrophy  of  lung-tissue  and 
capillaries  of  the  lung,  and  hence  diminished  breathing-surface.  More- 
over, it  will  be  understood  that  whenever  there  is  expiratory  dyspnoea, 
if  the  difficulty  of  expiration  is  not  equalized  by  forced  or  prolonged 
expiration,  there  must  result  a  simultaneous  inspiratory  dyspnoea ; 
there  is  a  diminished  interchange  of  gases  in  the  lungs  resulting  from 
the  incompleteness  of  the  act  of  expiration ;  there  is  a  demand  for 
oxygen,  and  hence  forced  inspiration.  There  is  no  expiratory  dyspnoea 
with  vicarious  emphysema  of  the  lungs. 

Mixed  dyspnoea — that  is,  where  it  is  manifest  in  equal  degree  in 
inspiration  and  expiration — is  by  far  the  most  frequent.  It  accom- 
panies all  the  diseases  of  the  respiratory  organs  not  mentioned  here, 
also  diseases  of  the  heart,  and  fever. 

Palpation  of  the  Thorax. 

This  method  of  examination  has,  on  the  one  hand,  an  independent 
value,  and  on  the  other  it  confirms  and,  with  sufficient  practice,  even 
adds  to  the  results  of  inspection.  It  is,  therefore,  very  wrong  to  omit 
it.  It  is  indispensable  on  account  of  its  simplicity,  and  because,  like 
inspection,  it  quickly  furnishes  a  result  in  a  general  way ;  moreover, 
its  result  is  often  decisive  in  diiferential  diagnosis,  in  a  certain  direc- 
tion, relative  to  vocal  fremitus. 

Palpation  of  the  thorax,  with  reference  to  the  respiratory  organs,  is 
made  for  the  purpose  of  ascertaining  : 

1.  Possible  pain  upon  pressure. 

2.  The  respiratory  movements  of  the  thorax,  especially  as  to 
symmetry, 

3.  Any  friction-sounds  or  rS,les  that  may  be  felt. 

4.  Vocal  fremitus. 

In  addition,  there  are  some  rare  appearances  that  are  not  unim- 
portant in  differential  diagnosis. 

The  examination  with  reference  to  the  first  and  second  points  may 
be  combined  with  inspection  ;  the  trial  of  the  third  point  may  suitably 
be  settled  during  auscultation,  either  before  or  after.  Ordinarily  we 
test  the  vocal  fremitus  after  the  completion  of  percussion  and  auscul- 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.        IQl 

tation,  hence  we  conclude   the  physical  examination  of  the  thoracic 
organs  by  noticing  the  vocal  fremitus. 

We  pause  here,  in  the  course  of  the  examination,  and  only  speak  of 
the  first  and  second  points ;  the  two  others  will  be  introduced  under 
the  heads  of  Percussion  and  Auscultation. 

1.  Pain  caused  by  Pressure  upon  the  Thorax. 

In  diseases  of  the  chest  pain  is  common,  accompanying  the  diseases 
or  elicited  by  pressure.  In  case  it  resjlly  refers  to  an  internal  organ, 
and  not  to  the  chest-wall,  it  indicates  disease  of  the  pleura  or  compli- 
cation with  the  pleura.  By  carefully  feeling  the  intercostal  spaces 
with  the  tips  of  the  fingers,  the  region  that  is  tender  on  pressure  may 
be  very  exactly  defined ;  it  is  generally  less  extensive  than  the  terri- 
tory of  spontaneous  pain,  since  the  latter  ordinarily  "radiates." 

This  tenderness  sometimes  exists  with,  exudative  pleuritis,  but  in 
this  disease  it  is  often  wanting ;  more  frequently  it  is  seen  in  croupous 
pneumonia  which  involves  also  the  pleura,  and  also  in  phthisis.  In 
the  latter  disease  it  generally  depends  upon  callous  thickening  of  the 
pleura. 

It  is  very  important,  but  also  frequently  difficult,  to  distinguish 
between  pleuritic  pains  produced  by  pressure  from  those  arising  in 
the  soft  parts  of  the  chest-ioall  or  the  ribs.  Phlegmonous  inflam- 
mations and  abscesses  of  the  chest  are,  of  course,  easily  recognized. 
Pain  proceeding  from  a  rib  is  generally  characteristic ;  quite  circum- 
scribed, it  occurs  only  when  pressure  is  made  upon  the  affected  rib 
(caries,  periostitis,  over  fractured  ribs,  slight  pressure) ;  also,  rheu- 
matism of  the  chest-muscles  occasions  no  great  difficulty,  at  least  when 
it  is  in  the  superficial  muscles ;  the  muscle  is  ordinarily  sensitive  if 
pressed  between  two  fingers.  On  the  other  hand,  it  is  often  not  easy 
to  distinguish  between  pleuritic  pain  and  intercostal  neuralgia  ;  the 
latter  can  sometimes  be  distinguished  by  Valleix's  points  of  tender- 
ness, which  stand  wholly  out  of  relation  to  deep  breathing  or  cough. 
(See  Nervous  System.)  It  is  important  to  remember  that  neuralgic 
intercostal  pain  may  be  present  in  affections  of  the  pleura,  as  in 
tubercular  thickening  of  the  pleura  in  the  lower  part  of  the  thorax. 

In  short,  we  ought,  in  the  absence  of  other  indications  which  point 
to  a  disease  of  the  internal  thoracic  organs,  to  refer  a  pain  produced 


102  SPECIAL  DIAGNOSIS. 

})j  pressure  upon  the  thorax  rather  to  something  else  than  to  the 
pleura ;  only  continuous  pain,  always  at  the  same  places,  over  the 
upper  sections  of  the  lungs,  arising  either  spontaneously  or  from 
pressure,  is  suspicious ;  this  may  indicate  irritation  of  the  pleura 
from  tuberculosis  of  the  apices. 

Structures  of  the  ribs  are  recognized  by  crepitation,  and  also  by 
dislocation  of  the  fragments  ;  also,  often  by  the  fact  that  pressure 
at  any  part  of  the  broken  rib  causes  pain  at  the  seat  of  fracture. 
Moreover,  fracture  of  the  rib  may  cause  pleurisy.  Caries  of  the  rib 
may  also  excite  pleurisy.  Then,  in  recognized  pleurisy,  caries  may 
be  proved  to  be  the  cause  by  the  circumscribed  pain  elicited  by 
pressure  upon  the  rib. 

It  must  also  be  mentioned  that  if  a  purulent  pleuritis  breaks  out- 
wai'd  (empyema  necessitatis),  it  causes  peripleural  inflammation,  and 
with  this  there  is  pain  upon  the  slightest  pressure,  besides  swelling, 
redness,  heat,  oedema  of  the  skin,  and,  lastly,  fluctuation. 

To  the  above-mentioned  conditions  revealed  by  palpation  of  the 
thorax  must  be  added  'pulsations  of  the  heart  felt  through  a  portion 
of  infiltrated  lung  lying  over  the  heart,  and  also  in  the  so-called 
empyema  pulsans  (empyema  pulsatile). 

This  occurs  when  there  is  an  accumulation  of  pus  lying  over  the 
heart,  almost  always  upon  the  left  side,  to  which  the  pulsation  of  the 
heart  is  communicated.  In  some  cases  it  is  very  difficult  to  distin- 
guish it  from  aneurism  of  the  aorta.  It  can  only  be  done  by  taking 
a  comprehensive  view  of  the  case.  (We  must  be  on  our  guard  in 
puncturing  or  in  making  an  exploratory  puncture.)  Sometimes  pulsa- 
tions are  even  found  on  the  left  lower  posterior  portion  of  the  thorax. 
Usually  several  causes  combine  to  produce  the  pulsation :  paresis  of 
the  intercostal  muscles,  higher  pressure  of  the  exudate,  direct  contact 
with  the  heart,  lastly,  as  indispensably  necessary,  powerful  action  of 
the  heart. 

2.   Testing  the  Movement  during  Respiration. 

With  special  reference  to  symmetry,  with  some  practice,  palpation 
is  a  most  excellent  method.  It  gives  more  exact  results  than  inspec- 
tion, and  makes  the  further  examination  easier,  in  that  it  directs  the 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.       103 

attention  immediately  to  the  diseased  side  or  the  region  of  the  thorax 
affected. 

The  respiration  is  examined  by  placing  the  two  hands  alike  upon 
the  two  sides  of  the  chest.  In  order  to  test  the  breathing  of  the  upper 
divisions  of  the  lungs,  place  the  hands  flat  in  front,  gradually  diverging 
below^  so  that  the  tips  of  the  fingers  reach  to  the  lower  border  of  the 
clavicle.  For  examining  the  lower  parts,  spread  out  the  hands  with 
the  thumbs  extended  so  that  the  thumbs  rest  upon  the  angle  of  the 
ribs.  Behind,  only  the  respiration  of  the  lower  lobes  will  be  tested 
by  laying  the  flattened  hands,  with  the  thumbs  extended,  upon  the 
surface  in  such  a  way  that  the  points  of  the  fingers  reach  about  to  the 
middle  axillary  lines. 

For  exact  examination,  it  is  necessary,  if  possible,  for  the  physician 
to  be  exactly  before  or  behind  his  patient ;  the  latter  position  espe- 
cially is  often  difficult  when  the  patient  sits  in  bed ;  it  is  best,  then,  to 
have  the  patient  slide  somewhat  down  toward  the  foot  of  the  bed. 

When  palpation  is  well  performed,  "lagging"  over  the  apex  in 
beginning  phthisis,  or  the  "  lagging  "  of  the  lower  part  of  one  side  in 
pneumonia,  pleurisy,  infarction,  etc.,  is  recognized  with  great  exact- 
ness ;  this  is  of  great  importance,  because,  as  I  have  already  said, 
"  lagging  "  may  be  in  many  diseases  for  some  time  the  only  symptom. 

We  may  also  test  the  action  of  the  diaphragm  with  reference  to  its 
symmetry  by  palpation.  We  place  the  hands  so  that  the  finger-tips 
cover  the  epigastrium  ;  in  this  way  may  be  detected  the  lack  of  con- 
traction upon  one  side  (pleuritis  diaphragmatica,  local  peritonitis, 
paralysis  of  one  phrenic  nerve).  Failure  to  contract  upon  both  sides 
is,  of  course,  seen  at  once. 

GENERAL   AND    PRELIMINARY   REMARKS    REGARDING  PERCUSSION.^ 

In  daily  life  we  learn  on  every  hand  that  bodies  of  different  physical 
structure  give  forth  different  sounds  when  struck.  We  also  sometimes 
strike  an  object  in  order  to  determine  from  the  sound  it  gives  forth 
what  its  physical  condition  is — that  is,  whether  it  is  hollow  or  solid. 

1  In  this  chapter  the  author  follows  in  many  ways,  but  not  entirely,  the  Tiews  and 
methods  of  presentation  of  Weil,  whose  personal  pupil  he  was  for  ten  years  and  whose 
teachings,  in  the  courses  upon  percussion  which  the  author  has  conducted  for  four 
years,  were  in  many  respects  a  rule  of  conduct  to  him. 


104  SPECIAL  DIAGNOSIS. 

This  is  the  principle  upon  which  percussion  is  practised  on  the  human 
body;  from  the  sound  elicited  by  the  blow,  we  judge  of  the  physical 
condition  of  the  part  which  lies  beneath  the  covering  of  the  body 
within  the  sphere  of  our  percussion-stroke. 

Hence,  percussion  gives  direct  information  regarding  organs  or 
parts  of  organs  which  lie  approximatively  near  to  the  surface  of  the 
body ;  in  general,  by  this  method,  we  penetrate  only  to  the  depth  of 
five,  or,  at  most,  seven  cm. 

1.  History  and  Methods. 

The  honor  of  the  discovery  of  percussion  belongs  to  a  physician  of 
Vienna,  named  Auenbrugger ;  the  paper  in  which  he  made  known 
his  method  appeared  in  1T61  under  the  title,  Inventum  novum  ex 
percussione  thoracis  humani  ut  signo  ahstrusos  interni  pectoris  morhos 
detegendi.  For  almost  half  a  century  Auenbrugger's  discovery  was, 
on  the  one  hand,  declared  to  be  without  importance,  and,  on  the 
other,  was  ridiculed,  until  the  year  1808,  when  Corvisart,  body 
physician  to  Napoleon  I.,  emphatically  revived  and  largely  improved 
it  by  a  translation  into  French,  with  a  commentary.  Then  the  truth 
began  really  to  prevail,  especially  by  the  influence  of  Piorry  in  France 
and  Skoda  in  Vienna.  The  former  was  the  founder  of  topographical 
percussion.  During  fifty  years  the  method  gradually  became  common 
professional  property.  Further,  and  up  to  the  most  recent  time,  it 
experienced  improvement  and  explanation  of  every  kind,  especially 
by  Wintrich,  Traube,  Biermer,  Gerhardt,  and  Weil.  For  several 
years,  especially  since  the  labors  of  Veil,  it  appears  that  a  degree  of 
certainty  has  been  reached  in  regard  to  this  proceeding. 

In  the  course  of  the  development  of  percussion  several  methods  of 
striking  the  body  have  been  discovered,  most  of  which  still  have  value 
to-day. 

Auenbrugger  struck  directly  upon  the  thorax  with  the  tips  of  the 
fingers  :  direct  or  immediate  percussion. 

Piorry  discovered  indirect  or  mediate  percussion.,  in  that  he  placed 
under  the  percussing  finger  a  small  plate  of  ivory — a  pleximeter. 

Wintrich  introduced  the  percussion-hammer,  which  had  already 
been  sometimes  used  by  Laennec  and  Piorry,  in  place  of  striking  with 
the  fingers. 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.       105 

But  finally,  in  more  recent  times,  the  method  of  indirect  percussion, 
without  instruments,  has  very  widely  prevailed.  The  index-  or  middle 
finger  of  the  left  hand  is  used  as  the  pleximeter,  which  is  placed  upon 
the  spot  to  be  percussed,  and  it  is  struck  with  the  index-  or  middle 
finger  of  the  right  hand  (finger-percussion). 

Of  these  methods,   that  of  Auenbrugger,  the   direct,    has    been 
dropped  as  being  less  practical,  while  now-a-days  the  three  in  use  are 
all  examples  of  the  indirect  method  : 
I.  Finger-percussion. 
II.  Finger-pleximeter  percussion. 

III.  Hammer-pleximeter  percussion. 

All  three  are  practised  and  taught  by  good  teachers  of  percussion ; 
all  three,  in  reality,  yield  equally  exact  results;  the  secret  of  their 
value  lies  in  their  application. 

One  who  thoroughly  understands  finger-percussion  can  very  quickly 
acquire  a  knowledge  of  the  two  other  methods.  Hence,  I  am  most 
heartily  in  accord  with  those  who,  in  their  teachings  and  writings, 
emphatically  recommend  their  students  at  first  to  practise  the  finger 
method  of  percussion  exclusively. 

I  think  it  superfluous  for  me  here  to  go  into  particulars  regarding 
the  technique  ;  these  can  only  be  made  clear  in  the  clinic;  but  I  must 
remark  that  the  greatest  difficulty  in  finger-percussion  is  in  holding 
the  percussing  finger  crooked,  like  a  hammer,  and,  at  the  same  time, 
having  the  wrist-joint  move  quite  freely.  Also,  the  numerous  forms 
of  percussion-hammers  and  pleximeters  (the  latter  of  glass,  ivory, 
hard  rubber,  and  wood,  in  different  forms)  cannot  be  described  here. 
It  appears  to  me  that  the  hammer  with  a  wooden  handle  and  a  metal 
head,  not  too  heavy,  is  rather  to  be  recommended;  likewise,  a 
medium-sized  oblong  ivory  pleximeter,  about  two  cm.  wide,  and  the 
so-called  double  pleximeter  of  Seitz.  Even  to  those  who  practise 
finger-percussion  this  last  is  recommended  for  percussing  the  supra- 
clavicular depressions.  There  is  one  point  of  great  importance  :  that 
the  individual  should,  as  much  as  possible,  be  homogeneous  in  his 
method  and  in  accord  with  it  throughout :  in  percussing,  if  the  finger 
method  is  used,  he  should  always  strike  upon  the  index-  or  always 
upon  the  middle  finger  of  the  left  hand ;  the  pleximeter,  if  that  is 
used,  should  always  be  used  in  exactly  the'  same  way,  etc.  Nothing 
is  worse  than  frequently  to  change  methods  or  instruments,  be  the 


106  SPECIAL  DIAGNOSIS. 

change  ever  so  slight.  But  if  physicians,  as  is  true  of  many,  are 
accustomed  at  certain  parts  of  the  thorax  where  it  is  difficult  to  use 
finger-pei-cussion,  regularly  to  employ  a  pleximeter,  or  both  pleximeter 
and  hammer,  there  is  no  objection  to  this  twofold  method ;  only  he 
must  be  master  of  the  two  methods  which  he  employs.  It  is  well, 
also,  always  to  repeat  the  same  method  upon  the  same  parts  of  the 
body. 

2.   Qualities  of  Sounds. 

By  our  striking  upon  the  body  we  cause  a  sound.  This  percussion 
sound  differs  according  to  the  condition  of  the  part  of  the  body  which 
is  shaken  by  our  percussion  blow. 

Two  principal  sentences  contain  the  foundation  of  percussion  ; 

1.  When  we  strike  upon  a  solid  portion  of  the  body  entirely  free 
from  air  we  elicit  a  toneless  sound  of  the  least  possible  intensity  and 
duration;  it  is  designated  as  "absolutely  deadened,"  or  as  a  "thigh 
sound,"  since  it  is  like  that  caused  by  striking  upon  the  thigh. 
[Deadness :  I  have  frequently  used  this  word  and  its  derivations  as 
giving  a  useful  and  accurate  discrimination  from  the  familiar  English 
terms,  flatness,  dulness.     Deadness  is  more  than  dulness.] 

2.  If  organs  containing  air  lie  in  the  range  of  our  percussion  blow, 
then  these  give  forth  a  sound  of  a  certain  intensity,  duration,  and 
tone ;  this  sound  is  designated  as  "  clear." 

The  clear  sound  of  organs  containing  air  may  have  only  a  different 
degree  of  intensity  or  clearness.     Its  intensity  depends  upon  : 

1.  The  length  of  the  oscillation.  It  is,  therefore,  stronger,  the 
stronger  the  blow;  and,  moreover,  the  nearer  the  organ  containing 
the^ir  is  to  the  percussing  finger — that  is  to  say,  the  less  the  per- 
cussion-stroke is  weakened  by  the  tissue,  as  fat,  muscles,  bones  [also 
clothing],  intervening  between  it  and  the  air-cavity. 

2.  By  the  volume  of  the  parts  of  the  air-containing  tissue  set  in 
motion. 

Hence,  with  equal  strength  of  percussion,  we  have  in  different 
parts  of  the  body  different  intensity  and  different  clearness  of 
sound,  according  to  the  greater  or  less  amount  of  air  which  the 
tissues  contain,  or  according  to  the  nearness  or  distance  of  the 
air-cavity  from  the  surface  of  the  body — that  is,  from  the  percussing 
finger. 

It  is  according  to  the  change  of  these  conditions  in  the  human 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.        107 


body  that  we  obtain  the  different  clear  sounds ;  we  may  meet  every 
grade  from  absolute  deadness  to  a  very  clear — the  peculiarly  clear — 
sound.  These  intervening  grades  are  designated  as  "  relative  dull- 
ness" (that  is,  in  comparison  with  a  real  clear  sound  it  is  dull). 


Fig.  16. 


Fig  ir. 


Fig.  18. 


Luttff 


Lrni^ 


Fig.  16. — Diagrammatic  representation  of  the  difference  between  weak  and  strong 
percussion  under  circumstances  that  are  otherwise  alike.  The  length  of  the  arrows 
corresponds  with  the  strength  of  the  percussion;  the  size  of  the  triangle  designates  the 
volume  of  the  portion  of  lung  affected  by  the  blow,  and,  at  the  same  time,  the  intensity 
of  the  sound. 

Fig.  17. — Eepresentation  of  the  difference  of  result  with  a  percussion-stroke  of  equal 
strength,  but  when  the  thickness  of  the  covering  of  the  body  varies.  Clear  sound, 
relatively  dull  sound,  no  resonance — that  is,  absolutely  dull  sound. 

Fig.  18. — Eepresentation  of  the  effect  upon  percussing  over  a  thick  covering  of  the 
body.  Over  the  apex  and  border  of  the  lung  the  sound  is  less  intense  than  over  the 
rest  of  the  lung,  on  account  of  the  diminished  volume  of  lung-tissue,  the  percussion- 
stroke  having  the  same  force,  and  this  tolerably  strong. 

Absolutely  dead  or  dull  sounds  differ  according  as  they  proceed 
from  muscle,  bone,  etc.  We  cannot  wholly  ignore  these  differences, 
as  if  not  existing. 

On  the  other  hand,  the  clear  sounds  fall  into  the  two  following 
important  divisions : 

1.  Tympanitic  sound  (the  name  is  from  tympanon;  the  kettle- 
drum or  tymbal,  not  exactly,  but  very  nearly,  produces  it).  This 
approaches  a  musical  note,  so  that  we  can  exactly  define  its  place  on 
the  musical  scale,  and  it  is  actually  shown  formed  from  regular  oscil- 
lations in  the  rotating  reflected  image  of  the  sensitive  gas-flame.  It 
shows,  also,  according  to  the  different  conditions  to  be  described  later, 
sharply  definable  differences  of  pitch.  A  tympanitic  sound  such  as  is 
frequently  met  with  in  the  body  can  easily  be  produced  if  one  strikes 


108  •  SPECIAL  DIAGNOSIS. 

upon  his  own  cheeks,  which  have  been  inflated,  but  not  too  strongly 
stretched. 

2.  The  clear  sound  called  non-tympa7iitic,  also  more  briefly  "lung- 
sound" — a  very  practical  designation.  This  has  no  sound  definable 
by  its  pitch,  but  yet  it  may  be  known  in  general  as  "  high  "  or 
"deep." 

Hence,  both  the  tympanitic  and  the  non-tympanitic  sound  have  a 
certain  intensity  and  duration;  but,  while  the  latter  only  approxi- 
matively  may  be  designated  as  high  or  deep,  the  pitch  of  the  tone 
brings  it  toward  the  tympanitic.  Both  occur  in  a  very  high  degree 
of  clearness  and  in  all  degrees  of  relative  dulness  ('•'  relative  dullness  " 
or  "  dull  tympanitic  sound"),  even  to  an  often  unnoticeable  transition 
to  absolute  dullness. 

1.  In  the  foregoing,  we  give  those  designations  which,  in  late 
years,  we  have  without  exception  employed  in  our  instruction  on  per- 
cussion. Regarding  the  large  number  of  other  terms  for  qualities 
of  sound  which  the  older  teachers  of  percussion  have  introduced, 
but  which,  to  the  great  advantage  of  clearness  of  mutual  under- 
standing, have  more  and  more  disappeared  from  the  literature  of  the 
subject,  we  refer  to  the  classical  work  by  Weil  on  Topographical 
Percussion.  We  have  in  fact,  as  will  be  seen,  followed  the  nomen- 
clature proposed  by  Weil,  with  only  one  exception  ;  the  term  dull  is 
avoided,  and  in  place  of  it  we  have  employed  the  expression  (which, 
it  is  true,  is  somewhat  circumstantial)  "absolutely  smothered,"  or 
"  thigh- sound."  This  was  done  because,  over  and  over,  we  found 
that  pupils  were  reminded  of  the  "dull  sound  of  the  kettle-drum," 
''  dull  roaring,"  etc.,  and,  hence,  were  confused  ;  in  short,  because  the 
expression  does  not  grammatically  designate  what  is  intended  in 
teaching  percussion.  "Absolute  smothered  sound  "  has  this  advantage 
— that,  to  the  beginner,  it  is  a  new  association  of  words ;  it  cannot, 
therefore,  so  easily  occasion  confusion.  Moreover,  the  expression 
alwaya  summons  one  to  a  more  exact  testing  as  to  whether,  at  the 
particular  place,  there  is  really  absolute  or  only  relative  dullness; 
and  every  teacher  of  percussion  knows  how  much  this  is  needed — 
that,  for  instance,  in  percussing  the  lower  part  of  the  right  mammil- 
lary  line  the  so-called  relative  liver-dullness  is  spoken  of  as  absolute 
dullness. 

2.  For  the  sake  of  brevity  and  clearness,  we  also  have  really  not 


EXAMINA  TION  OF  THE  RESPIRA  TOR Y  A PPA RA  TUS.       109 

gone  into  the  many  ideas  and  the  manner  of  explaining  them  pre- 
sented by  others,  on  this  subject,  which  was  formerly  quite  confused, 
and  is  even  yet  diflficult.  But  we  cannot  abstain  from  citing  here  the 
three  fundamental  sentences  from  Skoda  : 

{a)  All  fleshy  parts,  not  containing  air  (except  tense  membranes 
and  filaments),  also  fluid  accumulations,  give  an  entirely  dead  and 
empty,  scarcely  distinguishable  percussion-sound,  which  can  be  demon- 
strated by  striking  upon  the  thigh. 

(h)  Only  bones  and  cartilage  when  directly  struck  give  a  peculiar 
sound. 

{c)  Every  sound  which  we  elicit  by  percussing  the  thorax  and 
abdomen,  and  which  diff"ers  from  the  sound  of  the  thigh  or  bone, 
comes  from  air  or  gas  in  the  chest  or  abdominal  cavity. 

3.  The  acoustic  character  of  the  clear,  and  that  of  the  relative  or 
absolutely  dull,  sound  is  clearest  expressed  if  we  say :  the  dull 
sound  is  a  very  slight  noise  of  short  duration  ;  the  clear,  non-tym- 
panitic  sound  is  a  noise  louder  and  of  longer  duration,  Avith  a  trace 
of  being  a  note ;  this  latter,  however,  is  so  little  apparent  that  it 
either  cannot  at  all  be  recognized,  or  only  in  general,  as  to  its  being 
high  or  deep.  In  the  tympanitic  sound,  with  the  discordant  mingling 
of  tones,  a  tone  predominates  of  such  a  character  that  it  is  plainly 
heard  and  its  musical  pitch  distinguished. 

The  Qonditions  that  determine  the  Quality  of  the  Sounds  arid  their 
Production  in  the  Body. —  The  Feeling  of  Resistance. 

The  tympanitic  sound  exists : 

1.  Over  cavities  that  contain  air  or  gas,  if  they  are  surrounded  by 
walls  moderately  smooth  and  capable  of  reflexion,  and  if  they  com- 
municate with  the  external  air  through  an  opening,  the  walls  being 
stiiF  or  yielding.  The  intensity  of  the  tympanitic  sound  thus  pro- 
duced depends  upon  the  conditions  (mentioned  on  page  107)  influ- 
encing the  intensity  of  clear  sounds  in  general.  The  musical  pitch  of 
the  sound  is  determined  by  : 

(a)  The  size  of  the  communicating  opening ;  the  larger  it  is  the 
higher  the  tone. 

(6)  The  volume  of  the  cavity  containing  the  air ;  the  larger,  the 
deeper  the  tone. 


110  SPECIAL  DIAGNOSIS. 

(c)  If  the  walls  are  yielding,  membranous,  by  their  tension;  lax 
membranous  walls  make  the  tone  deeper. 

2.  Over  air-eontaining  cavities  with  yielding,  membranous  walls,  if 
the  cavities  are  closed — that  is,  do  not  communicate  with  the  external 
air ;  only  the  walls,  and  with  them  the  enclosed  air,  must  not  be  too 
tense.     Here  the  pitch  is  determined  only  : 

(a)  By  the  volume  of  the  air-cavity.     (See  above  under  h) 

(b)  By  the  tension  of  the  wall.     (See  above  under  c.) 

But  if  the  tension  of  the  wall  (and  with  it  the  enclosed  air)  of  a 
closed  cavity  reaches  a  certain  degree,  then  the  percussion-tone  be- 
comes clear  and  non-tympanitic.  Likewise,  cavities  that  are  closed 
on  all  sides  by  stiff  walls  give  a  non-tympanitic  sound. 

The  tympanitic  sound  mentioned  under  1  is  called  "open,"  that 
under  2  "closed;"  the  former  has  a  much  more  pronounced  tym- 
panitic character — that  is,  the  pitch  of  the  tone  appears  more  dis- 
tinctly than  the  latter. 

When  the  cavities  are  cylindrical,  communicating  outward  by  an 
opening,  the  pitch  of  the  tone  is  determined  by  the  length  of  the 
cylinder;  the  longer  it  is,  the  higher  the  tone.  Some  experiments, 
illustrating  what  has  been  said,  are  easily  performed  and  are  strongly 
recommended  to  beginners  :  Take  an  empty  Florence  flask  and  percuss 
upon  its  mouth,  either  directly  or  hold  the  pleximeter  lightly  over  its 
mouth,  then  diminish  the  quantity  of  air  by  partly  filling  the  bottle 
with  water;  if  possible,  also  compare  the  differences  of  pitch  which 
are  produced  by  different  lengths  of  the  neck  of  the  bottle,  other  con- 
ditions remaining  the  same.  Percuss  a  rubber  gas-bag  which  is  at 
first  only  moderately  inflated,  then  more  tensely,  with  air.  In  this 
way  one  can  very  easily  illustrate  the  most  important  of  the  laws  that 
have  been  mentioned. 

3.  Finally,  tympanitic  sound  occurs  under  quite  other  conditions, 
namely,  in  certain  conditions  of  the  lungs  which  have  this  in  common 
— that  they  probably  accompany  a  Avant  of  tension  of  the  lung-tissue. 

Referring  to  what  was  said  above  under  1,  we  add  that  the  open 
tympanitic  sound  occurs  in  the  human  body,  under  normal  relations, 
when  the  mouth.,  larynx,  and  trachea  are  percussed;  pathologically, 
when  percussing  lung-cavities  which  are  in  open  communication  with 
the  air-passages  ;  further,  if  in  consequence  of  shrinking  of  the  apices 
of  the  lungs,  the  trachea,  or  in  consequence  of  shrinking  or  thickening 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.       HI 

of  the  lung  where  it  covers  a  fissure,  a  primary  bronchus,  wouhl  be 
reached  by  the  percussion-stroke,  and  would,  therefore,  be  itself  per- 
cussed ;  and,  finally,  the  open  tympanitic  sound  sometimes  occurs  with 
opeyi  'pneumothorax. 

Herewith  we  notice  a  peculiarity  of  this  sound,  which  truly  stands 
iu  a  certain  (although  still  not  altogether  clear)  relation  to  the  laws 
above  enunciated  regarding  the  pitch  of  the  open  tympanitic  sound: 
the  sound  is  higher  with  the  mouth  open,  deeper  with  the  mouth 
closed.  If  this  occurs  when  percussing  a  lung-cavity  (or,  also,  in 
open  pneumothorax)  it  is  called  Wintrich's  change  of  sound;  if  on 
percussion  of  the  trachea  or  a  primary  bronchus,  then  we  speak  of 
Williams's  tracheal  tone. 

In  addition  to  what  was  said  above  under  2,  we  remark  that  in  the 
human  body  the  closed  tympanitic  sound  is  heard  over  the  stomach 
and  bowels ;  in  rare  cases  over  closed  pneumothorax ;  and,  finally, 
in  pneumopericardium. 

Now,  while  it  is  difficult  to  apply  the  rules  regarding  the  change  of 
pitch  to  the  open  tympanitic  sound,  since  the  cavities  of  which  we  are 
speaking  are  of  most  extremely  complicated  form  and  have  very  dif- 
ferent walls,  the  influence,  on  the  one  side,  of  the  volume  of  the  cavity, 
and  on  the  other,  the  influence  of  the  tension  of  a  membranous  wall, 
are  shown  over  the  stomach  and  intestines.  A  greater  volume,  as  in 
the  stomach  and  colon  in  comparison  with  that  of  the  small  intestine, 
deepens  the  sound  ;  while  increased  tension  heightens  it,  and  even 
renders  it  non-tympanitic. 

We  add  to  what  was  said  above  under  3,  that  the  normally  clear, 
non-tympanitic  sound  over  the  lung  becomes  tympanitic  if  the  tension 
of  the  lung-tissue  diminishes — i.  e.,  if  the  lung,  following  the  pull  of 
its  elasticity,  is  able  to  retract.  This  is  true  in  all  cases  where  the 
pleural  cavity  is  diminished,  hence,  especially  in  exudative  pleuritis. 
The  tympanitic  sound  is  found  where  the  retracted  lung  lies  against 
the  thorax.  All  the  other  changes  of  the  thoracic  and  abdominal 
cavities,  working  in  the  same  way  which  have  been  before  mentioned, 
occasion  these  phenomena. 

Probably,  for  the  same  reason — i.  e.,  in  consequence  of  the  relaxa- 
tion of  the  lung-tissue — a  tympanitic  sound  is  heard  in  croupous 
pneumonia  during  the  stages  of  engorgement  and  of  resolution ;  in 
oedema  of  the  lungs  ;  and,  finally,  in  the  neighborhood  of  thickened 


112  SPECIAL  DIAGNOSIS. 

parts  of  the  lungs.  In  the  latter  relation  the  tympanitic  sound  over 
the  apices  of  the  lungs  in  the  beginning  of  tuberculosis,  where  lung- 
tissue  containing  air  is  situated  between  groups  of  small  tubercular 
masses,  is  of  some  diagnostic  importance. 

In  these  cases  we  must  assume  that  the  lung-tissue  has  become 
loose  and  ductile,  and  has,  therefore,  lost  its  power  of  stretching.  It 
has  not  yet  been  established  that  this  explanation  is  correct. 

Metallic  sound.  We  thus  designate  such  a  variety  of  tympanitic 
sound  by  which  a  metallic  character,  produced  by  a  very  high  over- 
tone, either  occurring  with  the  sound  itself,  a  peculiar  metallic  tone, 
or  it  is  produced  afterward,  metallic  after-sounds.  The  metallic  sound 
exists  over  not  too  small,  very  smooth-walled,  regular  cavities,  both  open 
and  closed.  Hence,  we  find  it  sometimes  over  the  normal  stomach, 
intestines,  amd  sometimes  over  lung-cavities,  in  pneumothorax,  pneumo- 
pericardium. It  is  best  brought  out  in  percussing  with  the  so-called 
rod  pleximeter,  or  in  percussion-auscultation  (Heubner).     (See  later.) 

The  clear  non-tympanitic  sound  occurs  where,  "  within  the  sphere 
of  action  of  acoustics,  there  is  found  tissue  containing  air,  but  whose 
capacity  for  vibration  is  more  diminished  than  in  those  cases  in  which 
the  tympanitic  sound  occurs"  (Weil,  Handbook  of  Topographical 
Percussion,  2d  ed.,  p.  35).  It  is  heard  over  the  normal  lungs — a 
remarkable  fact,  since  a  lung  that  has  been  removed  from  the  body, 
even  if  it  is  inflated  to  a  volume  corresponding  with  the  condition 
during  life,  gives  a  sound  that  more  nearly  approaches  the  tympanitic 
than  the  non-tympanitic.  Why  a  lung  in  the  thorax  loses  wholly  the 
tympanitic  character  of  its  sound  is  not  entirely  clear ;  but  we  cannot 
help  thinking  that,  in  some  way  or  other,  the  chest-wall  is  the  cause. 

The  intensity  of  this  lung-sound  is  sufficiently  explained  by  the 
rules  given  above ;  its  pitch,  only  approximately  recognizable,  is 
chiefly  influenced  by  the  tension  of  the  lung-tissue.  We  have  men- 
tioned above  that  retracted  and  relaxed  lung-tissue  gives  a  tympanitic 
sound ;  if  the  tension  is  only  slightly  diminished,  then  there  is  only  a 
very  deep  (and  abnormally  clear)  non-tympanitic  sound.  This  occurs, 
also,  in  emphysema  of  the  lungs,  but  sometimes  in  exudative  pleurisy, 
and  also  in  pneumonia  in  the  air-containing,  infiltrated  adjacent  sec- 
tions of  the  lungs.  The  transition  from  the  non-tympanitic  to  the  tym- 
panitic sound  over  the  lungs  may  be  thus  summarized :  According  to 
the  diminution  of  the  normal  tension  of  the  healthy  lungs,  there  takes 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.        113 

place  in  the  thorax  a  change  of  the  clear  non-tympanitic  sound  to  an 
abnormally  clear  and  deep,  and,  in  very  marked  relaxation,  to  a 
tympanitic  sound.  To  the  above  corresponds  the  fact  that  in  very 
deep  respiration,  at  the  height  of  inspiration,  at  many  points  of  the 
thorax,  the  respiratory  sound  is  distinctly  higher,  Avhile  in  deep 
expiration  it  is  deeper  ("  change  of  respiratory  sound,"  Friedreich). 

Moreover,  we  hear  the  lung-sound  over  the  stofnach  and  bowels,  if 
they  are  very  much  inflated  with  gas,  where  gas,  as  well  as  wall,  is 
under  marked  tension ;  finally,  in  entrance  of  air  into  the  cavities  of 
the  body,  in  case  their  walls  are  thereby  made  tense ;  this  especially 
happens  in  most  cases  of  prieumothorax  (except  that  open  pneumo- 
thorax frequently  gives  a  tympanitic  sound).     (See  above.) 

The  deadened  sound.  Absolutely  deadened  or  thigh-sound  is  met 
with  "  if  only  structures  that  are  free  from  air  lie  within  the  sphere 
where  the  percussion-stroke  acts  acoustically  "  (Weil).  Since  this,  at 
best — i.  e.,  with  the  strongest  percussion — reaches  only  to  the  depth 
of  six  to  seven  cm.,  and  not  so  much  as  this  in  a  lateral  direction, 
therefore,  in  case  of  only  strong  percussion,  absolutely  deadened  sound 

Fig.  19. 

Entirely  deadened  :         >J 

Clear :  ^^^  " 


Covering  of  the  body  : 


Diagrammatic  representation  of  percussion  over  a  thick  covering  of  the  body.  The 
short  arrow  indicates  weak,  the  long  one  strong,  percussion.  "With  weak  percussion  we 
have  absolutely  deadened  resonance;  with  strong  percussion  a  clear,  although  less 
intense,  sound  (indicated  by  the  hatched  triangle). 

would,  after  all,  be  found  where  we  percussed  over  airless  structure 
of  sufficient  size,  in  case  an  organ  containing  air  was  not  directly  in 
contact  with  it.  If  we  percuss  still  less  strongly,  we  should,  as  a 
matter  of  course,  the  sooner  receive  an  absolutely  deadened  sound. 

In  the  human  body  we  have  next  to  consider  the  internal  organs 
not  containing  air,  called  "  parietal  "  if  they  lie  in  contact  with  the 
wall  of  the  body ;  and,  also,  the  coverings  (subcutaneous  fat,  muscles, 


114  SPECIAL  DIAGNOSIS. 

bones)  if  they  are  of  sufficient  magnitude.  Thus,  frequently,  in  the 
neighborhood  where  the  heart  is  parietal,  and,  further,  where  the  liver 
also  is,  even  with  strong  percussion  there  is  absolutely  deadened  sound. 
Not  infrequently,  however,  especially  over  the  heart,  absolute  deaden- 
ing does  not  exist,  since  the  structures  containing  air  lying  under  or 
near  by  may  be  reached  chiefly  through  transmission  by  the  chest- 
wall,  though  it  may  be  only  by  its  vibration,  and  may  give  the  clear 
sound  belonging  to  the  air-containing  structures. 

As  regards  the  skeletal  coverings,  in  abnormally  fat  persons,  and 
in  oedematous  diseases,  these  sometimes  attain  such  proportions 
that  even  strong  percussion  yields  an  absolutely  deadened  sound ;  in 
normal,  moderately  fat  persons  it  is  only  the  fossa  infraspinata  that 
very  frequently  gives  absolutely  dull  sound. 

But,  further,  parietal  tumors,  and  especially  Jluid  accumulations 
in  the  pleura  and  peritoneum  (more  rarely,  thickening  of  the  lungs), 
occasion  absolutely  deadened  sound  in  case  they,  together  with  the 
skeletal  covering,  possess  sufficient  depth  and  breadth. 

Moreover,  over  ribs  markedly  bowed,  as  over  the  point  of  sharpest 
bending-out  of  the  thorax  in  kypho-scoliosis,  absolutely  deadened 
sound  may  take  the  place  of  the  lung  sound;  also,  here,  often  a 
peculiar  change  of  the  lung  (aplasia)  plays  some  part. 

Relatively  dull  sound  occurs  where  air-containing  structures  of 
only  small  size  are  percussed,  or  where  structures  containing  air  are 
made  to  vibrate  only  slightly  by  percussion,  or  where  these  two  con- 
ditions are  met  with  together.  Thus,  a  relatively  dull  sound  is  ob- 
tained with  feeble  percussion  of  air-containing  structures,  while  strong 
percussion  of  the  same  yields  a  clear  sound ;  the  blow  reaches  only  a 
small  volume  of  the  air-containing  organ,  and  it  moreover  causes  in 
it  oscillations  of  only  moderate  amplitude.  Likewise,  where  the 
volume  of  lung-tissue  is  small,  as  over  the  apices  and  just  over  the 
lower  border  of  the  lungs,  the  sound  is  relatively  dull,  and  this  is 
true  even  with  strongest  percussion,  since  there  is  here  only  a  small 
portion  of  air- containing  material  to  be  acted  upon.  Finally,  every 
layer  of  airless  tissue  which  lies  over  an  air-containing  tissue  or  space 
causes  a  deadening  of  the  percussion-sound  of  the  latter — i.  e.,  a  rela- 
tively deadened  sound — if  the  overlying  layer  is  not  so  thick  as  to 
cause  an  absolutely  deadened  sound.  Subcutaneous  fat,  muscles, 
bones,  parietal  tumors,  thickening  of  lungs,  layers  of  fluid,  callosities 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.        II5 

— all  these,  as  overlying  airless  masses,  deaden  the  sound  in  proportion 
to  their  size. 

A  special  description  is   required  both  of  parietal  and  of  deeply 
seated  airless   'parts  which   normally   contain   air,   such    as    appear 


Fig.  20. 


Clear :  -       _ 

^L  No  differenca  __ 

Belatively  dull :  — *^^  clearness 


in  I  W 

,s:j ^1 


Lunff  H^         liVJitf 


Weak  percussion.  Strong  percussion. 

Diagrammatic  representation  of  the  value  of  gentle  percussion  in  determining  parietal 
condensation  in  the  lungs.  The  length  of  the  arrow  indicates  the  strength  of  the  per- 
cussion, the  size  of  the  hatched  triangle  the  extent  of  the  vibrations  in  breadth  and 
depth.  We  notice  that  weak  percussion  is  better,  because  it  gives  a  deadened  sound 
over  the  thickening,  while  over  the  lung  it  gives  a  clear  sound. 

especially  in  the  lungs  as  aoute  and  chronic  pneumonic  thickenings, 
infarction,  and  tumors  For  ascertaining  such  solidifications  it  is 
necessary  not  to  percuss  too  strongly ;  then  we  shall  plainly  make 

Fig.  21. 
Clear :  ■ 


Absolutely  dull ; 


• 


Less  difference 
in  clearness : 


Lung  fii    J^^  Lung 


Strong  percussion.  Weak  percussion. 

Diagrammatic  representation  of  the  value  of  strong  percussion  in  determining  con- 
densation in  the  lungs  lying  at  some  distance  from  the  surface.  The  strength  of  the 
percussion-stroke  is  indicated  by  the  length  of  the  arrows.  The  hatched  triangle  shows 
the  extent  of  the  oscillations  in  breadth  and  depth. 

out  the  place  where  there   is  air  by  the  diiference  in  sound,  if  the 
given  patch  of  thickening  measures  as  much  as  about  five  cm.  in 


11(5  SPECIAL  DIAGNOSIS. 

breadth  and  two  cm.  in  depth  (see  Fig.  20).  Deposits  which  are 
located  at  about  three  to  four  cm.  in  depth,  if  they  are  correspond- 
ingly large,  may  be  detected,  but  only  by  very  strong  percussion; 
then  we  elicit  a  relatively  deadened  sound  in  the  midst  of  what  is 
quite  normal,  as  is  shown  by  Fig.  21. 

Sensation  of  Resistance. — We  introduce  here  the  description 
of  this  symptom,  although  it  really  belongs  under  Palpation,  but  in 
truth  it  is  most  intimately  connected  with  Percussion. 

With  the  percussing  finger  (less  distinctly  with  the  hammer)  the 
examiner  forms  an  opinion  of  the  degree  of  resistance,  or,  to  express  it 
better,  concerning  the  degree  of  capacity  of  the  "parts  lying  beneath  it 
to  vibrate.  This  feeling  of  resistance  is  strongest,  the  power  to  vibrate 
least  conceivable,  where  it  is  absolutely  deadened,  the  sound  identical 
with  the  "thigh  sound";  hence,  normally,  where  we  strike  upon  thick 
muscle,  also  bones  and  muscles ;  pathologically,  it  is  especially  distinct 
over  large  pleuritic  exudations,  very  thick  pleura,  solid  parietal 
tumors  of  the  chest;  over  large  solid  abdominal  swellings ;  and  in 
extremely  rare  cases,  in  extensive  thickening  of  lungs,  where  the 
bronchi  are  completely  stopped  (as  in  the  so-called  "  massive  pneu- 
monia "  of  the  French. 

When  the  percussing  hammer  is  used,  to  ascertain  the  feeling  of 
resistance  the  index-finger  is  placed  upon  the  head  of  the  hammer. 
This  has  always  seemed  to  me  a  very  poor  substitute  for  finger- 
percussion. 

Other  authors,  as  Weil,  find  a  marked  feeling  of  resistance  only  over 
massive  layers  of  fluid.  I  have  often  convinced  myself  of  the  presence 
of  marked  resistance  in  the  cases  above  mentioned. 

4.  Topographical  Percussion :  Determining  the  Parietal  Boundaries 

of  Organs. 

Only  of  a  part  of  the  internal  organs  can  we  determine  the  bound- 
aries by  percussion  on  the  surface  of  the  body.  The  conditions  of  such 
determinations  are  these : 

(a)  That  the  given  organ  be  parietal. 

[b]  That  it  yield  a  sound  differing  from,  its  surrounding  tissues. 
Hence  we  can  mark  off  the  boundaries  of  a  parietal  organ  that  gives 

an  absolutely  deadened  sound  from  one  that  gives  a  clear  (tympanitic 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.       WJ 

or  non-tympanitic)  sound,  as  the  liver  from  the  lung  or  stomach,  the 
heart  from  the  lung;  of  a  parietal  organ  that  gives  a  tympanitic 
sound  from  one  that  yields  a  non-tympanitic  sound,  as  the  lung  from 
the  stomach  or  the  intestine ;  of  parietal  organs  with  tympanitic 
sounds  of  different  pitch,  as  the  stomach  from  the  intestines ;  and 
also,  though  very  seldom,  two  organs  of  non-tympanitic  sound,  in  case 
they  are  of  very  different  pitch,  as  pneumothorax  from  lung  lying 
against  the  opposite  side. 

But  we  can  never  recognize  the  boundaries  between  two  organs 
giving  deadened  sound  (heart  and  lungs),  nor  between  the  heart  and 
fluid  effusion  in  the  pleura  (see  below). 

Method  of  Determining  the  Boundary. — Generally  we  percuss 
from  an  organ  that  yields  a  clear  sound  toward  that  which  gives  a 
deadened  sound  and  upon  the  line  which  stands  perpendicular  to  the 
expected  boundary-line  (hence  the  pleximeter  or  the  pleximeter-finger 
is  placed  parallel  to  the  boundary-line).  We  proceed  by  long  stages 
upon  this  perpendicular  (striking  it  at  intervals  of  about  3  cm.), 
until  the  sound  has  so  distinctly  changed  that  we  are  convinced  that 
we  are  over  another  organ.  Then  we  define  the  boundaries  by  placing 
the  pleximeter  at  shorter  and  shorter  intervals  until  we  have  defined 
the  boundaries  as  sharply  as  possible.  This  is  traced  by  means  of  a 
blue  pencil.  After  the  boundaries  have  been  determined  at  various 
points  and  they  have  been  thus  marked,  then  the  points  are  united  in 
a  line,  which  is  the  boundary-line  of  the  particular  organ.  TJte  rule 
most  important  to  observe  is  to  percuss  very  lightly  along  the  border 
of  the  organ  ive  are  trying  to  locate. 

It  is  easy  to  see  the  reason  for  this  :  1.  By  strong  percussion, 
as  of  the  liver  close  to  the  lower  border  of  the  lungs,  we  should  at  the 
same  time  disturb  the  adjacent  lung  and  so  would  elicit  a  noticeable 
clear  sound,  and  we  should  then  easily  think  that  we  were  still  over 
the  lung.  In  the  same  way,  in  determining  the  lower  border  of  the 
liver,  by  strong  percussion  we  disturb  the  intestine  which  here  lies 
under  the  thin  portion  of  the  liver,  and  so  get  a  tympanitic  tone. 

2.  The  ear  perceives  the  very  slight  differences  of  sound  which  exist 
upon  the  border-line  (we  remember  the  lower  border  of  the  lung,  how 
the  clear  sound  yielded  by  it  must  have  slight  intensity)  better  if  the 
sound  is  itself  slight. 

For  those  who  are  trained,  the  simplest  method  may  be  recom- 


118  SPECIAL  DIAGNOSIS. 

mended,  that  on  approaching  the  boundary  between  the  two  organs  one 
should  successively  percuss  the  more  lightly. 

After  this  indispensable  explanation  of  the  general  rules  for  per- 
cussion, we  again  take  up  in  succession  the  methods  of  examination  of 
the  respiratory  organs. 

PERCUSSION    OF    THE    THORAX,  ESPECIALLY    OF    THE    LUNGS. 

1.  Methods. 

It  is  best  first  to  percuss  patients  who  are  out  of  bed  in  the  stand- 
ing posture,  and  later,  if  necessary  for  the  front  of  the  chest,  lying 
down.  Upon  bedridden  patients  the  examination  of  the  chest  is  con- 
ducted with  the  patient  in  the  dorsal  position  ;  for  percussing  the 
back,  we  have  the  patient  sit  up.  We  must  then  take  care  that  the 
patient  sits  in  a  symmetrical  position,  but  with  the  least  possible  ten- 
sion of  muscles ;  the  head  is  held  exactly  straight,  and  especially  in 
percussing  the  supraclavicular  depressions  it  must  not  be  turned ;  in 
the  dorsal  position  the  arms  lie  quietly  by  the  side  of  the  thorax. 
Both  in  sitting  and  standing  the  patient  bows  the  back  a  little,  in- 
clines the  head  slightly  forward,  allows  the  shoulders  to  hang  and 
folds  the  forearms  across  the  chest.  Every  contracting  muscle  in- 
creases the  thickness  of  the  covering  by  its  swelling  and  increases  the 
impression  of  dulness ;  hence  contraction  of  the  muscles  of  the  thorax 
must  as  much  as  possible  be  prevented. 

In  finger-percussion  of  the  front  of  the  chest  with  the  patient  in  the 
dorsal  position,  we  approach  the  bed  if  possible  so  as  to  stand  on  the 
left  side  of  the  patient.  From  the  other  side  it  is  not  possible  to 
place  the  finger  of  the  left  hand,  used  as  a  pleximeter,  symmetrically 
(see  below)  upon  the  two  sides  in  both  supraclavicular  spaces. 

We  proceed  in  such  a  way  as  to  compare  at  every  situation  the 
percussion-note  of  points  that  are  symmetrically  located.  We  must 
take  particular  care  to  strike  exactly  upon  symmetrical  points,  other- 
wise the  "comparative  percussion"  has  no  value.  Moreover,  since 
we  wish  to  make  an  exact  comparison  throughout,  we  take  care  also 
not  only  to  percuss  at  symmetrical  points,  but  to  percuss  with  equal 
strength,  and  somewhat  moderately. 

We  first  percuss  the  supraclavicular  depressions,  first  on  the  right. 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS        119 

then  on  the  left,  wliereby,  in  cases  where  it  is  of  special  importance, 
we  determine  the  upper  boundaries  of  the  apices  of  the  lungs ;  then, 
in  the  same  way,  the  infraclavicular  spaces  are  percussed ;  on  the  two 
sides  in  finger-percussion  we  must,  if  possible,  hold  the  pleximeter 
band  in  such  way  as  always  to  have  the  wrist  toward  the  middle  line 
of  the  thorax  and  the  pleximeter  finger  pointing  outward. 

Then  we  percuss  the  third  intercostal  space  right  and  left,  then 
downward  only  on  the  right,  and  usually  only  in  the  intercostal 
spaces.  We  do  not  further  compare  it  with  the  left  side,  since  the 
heart  lies  here,  which  is  percussed  by  itself  Then  follows  the  deter- 
mination of  the  right  lower  border  of  the  lungs  according  to  the  rules 
given  above  regarding  the  determination  of  parietal  organs.  We 
percuss  upward,  comparing  the  two  sides  of  the  thorax,  again  in  the 
intercostal  spaces.  When  we  wish  to  percuss  high  in  the  axillae,  the 
arms  are  to  be  abducted.  Then  follows  the  determination  of  the 
boundaries  of  the  rio;ht  and  left  borders  of  the  lungs  in  the  middle 
axillary  lines.  Sometimes  it  is  valuable  also  to  percuss  from  the 
infraclavicular  spaces  sideward  and  downward  upon  a  line  which  is  at 
right  angles  with  the  course  of  the  ribs. 

In  percussing  the  back  we  first  compare  the  sound  over  the  apices 
of  the  lungs,  thus  completely  defining  their  upper  boundaries ;  then  we 
percuss  on  the  right  and  the  left,  comparing  corresponding  intercostal 
spaces  as  we  proceed  downward  to  the  lower  borders  of  the  lungs. 
Then  we  percuss  on  the  sides  of  the  spine  below  the  angles  of  the 
scapulae,  comparing  symmetrical  points.  The  boundaries  of  the  lungs 
are  best  determined  in  the  scapular  lines. 

In  this  way  the  thorax  is  generally  to  be  percussed.  But  the 
presence  of  pathological  conditions  that  require  one  to  be  especially 
careful  in  the  examination  of  certain  parts  may  give  the  preference  to 
special  methods  of  examination.  These  have  been  in  part  already 
mentioned  in  the  general  division.  They  follow  directly  from  what 
was  said  there.  They  will  be  again  mentioned  in  the  description  of 
percussion  in  pathological  conditions  of  the  lung. 

2.  Normal  Sound  over  the  Lungs,  Trachea,  and  Larnyx.     The 
normal  boundaries  of  the  lungs. 

It  is  shown  that  in  percussion  of  the  lungs  in  general  over  the 
normal  lung  there  is  elicited  a  non-tympanitic  sound.    But  this  sound 


120  SPECIAL  DIAGNOSIS. 

as  regards  its  intensity  is  individually  very  different  in  diiFerent 
persons,  also,  in  each  single  chest  it  is  not  alike  throughout,  but 
exhibits  individual  regional  differences. 

The  individual  variations  arrange  themselves  first  according  to  the 
amount  of  fat.  Very  fat  bodies  give  a  less  clear  thoracic  sound,  or  in 
order  to  yield  a  clear  sound  they  must  be  percussed  more  strongly, 
requiring  perhaps  the  use  of  the  hammer ;  but  it  is  evident,  as  we 
have  said,  that  this  is  unfavorable  for  determining  the  boundaries, 
for  which  the  rule  is  to  employ  very  light  percussion. 

Farther,  the  percussion-note  of  the  chest  differs  according  to  age  : 
with  children,  having  a  more  elastic  thorax,  as  well  as  with  aged  per- 
sons with  thin  structural  coverings  and  somewhat  lax  or  rarefied 
lungs,  it  is  higher  in  pitch  than  in  persons  in  middle  life. 

But  also  in  the  individual  thorax  the  different  regions  normally 
give  .different  clearness  of  sound  In  other  words,  one  region  com- 
pared with  another  yields  a  relatively  deadened  sound,  and  according 
to  the  two  chief  points  of  view  previously  mentioned,  namely,  accord- 
ing to  the  varying  thickness  of  the  covering  and  according  to  the  size 
of  the  lungs.     Hence  we  remark  the  following  facts : 

{a)  Over  the  apices  of  the  lungs,  even  with  strong  percussion,  the 
sound  is  not  very  intense ;  for  though  the  covering  is  thin,  the  volume 
of  the  lung  tissue  is  small. 

(J)  In  the  infraclavicular  spaces,  and  still  more  in  the  second  inter- 
costal spaces,  the  sound  is  very  intense  (covering  thin,  more  lung 
tissue). 

((?)  Farther  down,  not  only  in  the  male,  but  in  still  higher  degree 
in  the  female,  the  sound  is  deadened  by  the  pectoral  muscle  or  by  this 
and  the  mamma ;  in  the  female  the  sound  may  be  absolutely  deadened 
over  the  mamma ;  and  this  notwithstanding  the  fact  that  the  lung- 
tissue  is  here  very  considerable. 

(d)  Upon  the  back,  the  apices  yield  a  sound  of  very  slight  inten- 
sity, since  here  there  is  a  very  small  volume  of  lung  and  a  very  thick 
body  of  muscle.  Over  the  scapuloe  there  is  likewise  a  very  deadened 
sound,  at  the  spine,  and  directly  below,  even  a  thigh-sound.  In  the 
interscapular  spaces  the  sound  is  clearer. 

(g)  Below  the  scapuloe  and  at  the  sides  of  the  chest  the  sound  is 
very  intense. 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.       121 

(/)  Strictly  speaking,  here  also  belongs  the  description  of  the  so- 
called  ^'•relative  heart  and  liver  deadeyiing."     (See  page  124.) 

Now,  it  is  further  very  important  to  know  which  similarly  situated 
points  on  the  thorax  normally  give  the  same  kind  of  sound,  since  it  is 
especially  by  comparative  percussion  that  we  seek  to  ascertain  the 
presence  of  disease  on  one  side.  We  may  say  that  in  healthy  people 
marked  dissimilarity  of  sound  at  symmetrical  parts  of  the  chest  on 
the  right  and  left  sides  exists  only  : 

In  tlie  neigJihorhood  of  ,the  heart,  as  compared  with  the  corre- 
sponding part  on  the  right. 

At  the  two  sides:  on  the  left  side  normally  the  sound,  almost  as  far 
back  as  the  spine  and  forward  in  front  at  varying  height  as  far  some- 
times as  the  fourth  rib,  is  often  clearer  than  on  the  right,  and  of  some- 
what tympanitic  tone  (combining  with  the  sound  of  the  stom.ach  or 
colon). 

In  addition,  there  is  a  slight  inequality  sometimes  posteriorly  over 
the  apices.  In  right-handed  persons,  the  sound  on  the  right  side  at 
that  location  may  sometimes  be  met  with  a  little  less  clear,  because 
the  muscles  are  somewhat  more  developed.  On  the  left  side,  in  left- 
handed  persons,  the  case  is  reversed. 

Lastly,  it  is  necessary  to  mention  a  point  of  greater  importance — 
that  over  the  whole  sternum  there  is  a  clearer,  non-tympanitic  sound, 
even  where  there  is  no  lung-tissue  at  all,  as  at  the  upper  part  of  the 
manubrium  (trachea)  and  over  the  left  half  of  the  lower  part  of  the 
corpus  sterni.  The  sternum  acts  as  an  unusually  thick  pleximeter, 
and  yields  therefore  throughout,  and  in  equal  strength,  the  sound  of 
the  lung  lying  in  contact,  spread  out  over  its  inner  surface. 

The  larynx  and  trachea  in  the  neck  in  front  give  the  tympanitic 
sound  of  a  hollow  cavity  with  smooth  walls.  This  has  the  peculiarity 
of  being  higher  and  more  plainly  tympanitic  with  the  mouth  open  than 
with  it  closed  (Williams's  tracheal  tone,  tracheal  change  of  sound). 
The  cause  oi  this  phenomenon  is  not  quite  clear;  the  explanation 
given  by  Neukirch,  and  accepted  by  Weil,  is  based  upon  the  assump- 
tion of  the  resonance  of  the  mouth  changing  with  its  opening  and 
closing.     This  will  be  referred  to  later. 

Normal  Percussion-boundaries  of  the  Lungs.  —  It  is  not 
possible  to  define  the  boundaries  of  the  lungs  perfectly  by  percussion. 
Moreover,  by  percussion  we  can  only  establish  : 


122 


SPECIAL  DIAGNOSIS. 


1.  The  apices  so  far  as  they  rise  above  the  clavicle :  they  are  dis- 
tinguished by  their  clear  sound  in  comparison  with  the  deadened 
sound  of  their  surrounding  soft  parts. 

2.  The  boundaries  of  the  left  lung  at  the  incisura  cardiaea :  the 
lung  sound  from  the  absolutely  deadened  sound  of  the  heart — the 
lung-heart  boundary. 

3.  The  lower  borders  of  the  lungs,  this  especially  at  the  lower 
border  of  the  right  lung :  the  lung  sound  marks  the  boundary  of  the 
absolutely  deadened  sound  of  the  liver — the  lung-liver  boundary. 

Fig.  22. 


Boundary  of  the  lungs  as  determined  by  percussion  in  front.  (After  Weil.)  g  h,  the 
extent  of  the  lung  upward;  ef,  the  lower  limit  of  the  lungs;  h  d,  the  relations  of  the 
lung  and  heart  at  the  incisura  cardiaea.  The  strongly-hatched  surface  represents  the 
portions  of  the  heart  and  liver  which  are  parietal ;  the  lighter  hatching  shows  the  so- 
called  relative  heart  and  liver  deadness.     (See  below.) 

At  the  lower  border  of  the  left  lung,  first  about  from  the  mam- 
millary  to  the  middle  of  the  middle  axillary  line,  the  lung  sound 
marks  the  boundary  of  the  tympanitic  sound  (stomach,  or  more  rarely 
also  intestines) — lung-stomach  boundary  ;  next,  the  lung  sound  from 
the  deadened  sound  of  the    spleen — lung-spleen  boundary;    and, 


EXAMINATION  OF  THE  RESPIRATOR V  APPARATUS.        123 


lastly,  from   the   deadened  sound   of   the  kidney — the   lung-kidney 
boundary. 

It  is  difficult  to  determine  the  boundaries  of  the  lungs,  since  the 
difference  of  sound  is  often  slight,  especially  as  the  tympanitic  sound 
of  the  stomach  often  mingles  with  the  lung  sound  higher  up  than  the 
anatomical  border  of  the  lower  limits  of  the  lung;  moreover,  the 
lower  boundaries  of  the  lungs  close  up  to  the  spine  on  both  sides, 
because  of  the  thick  layers  of  the  erector  spinge,  require  strong  per- 
cussion, and  this  is  unfavorable  for  determining  the  boundaries.  (See 
above.) 

Fig.  23. 


Boundary  of  the  lungs  as  determined  by  percussion  upon  tlie  back.     (After  Weil.) 
a  h,  the  upper  limits  of  the  lungs;  c  d,  lower  limits. 

We  cannot  determine  by  percussion  the  front  borders  of  the  lungs 
behind  the  sternum.  This  is  the  case  because  the  lungs  lie  close  to 
each  other  for  some  distance  there,  and  also  because  the  sternum,  like 
a  firm  bone,  yields  a  uniform  sound  and  it  is  not  possible  to  recognize 
a  difference  of  sound  in  what  lies  beneath  it :  it  yields  throughout  a 
clear  sound,  very  like  the  lung  resonance  over  the  ribs. 


124  SPECIAL   DIAGNOSIS. 

Hence,  it  may  also  be  explained  that  the  lower  part  of  the  anterior 
border  of  the  right  lung,  which  behind  the  sternum  is  limited  by  the 
heart,  cannot  be  defined  by  percussion ;  we  much  more  receive,  in- 
stead of  the  actual  boundary  of  the  right  lung,  one  that  is  apparent 
— where  the  uniform  sternal  sound  is  exchanged  for  the  absolutely 
deadened  sound  of  the  heart  at  the  left  border  of  the  sternum.  In  front 
the  base  of  the  right  lung  does  not  extend  so  far  down  as  the  left — 
the  right  coming  as  low  as  the  inferior  border  of  the  fifth  rib,  while 
the  left  corresponds  with  the  superior  border  of  the  sixth  rib. 

Relative  heart-  and  liver-dullness.  The  determination  of  the  lung- 
heart  and  the  lung-liver  boundaries  is  made  more  difficult  by  the 
peculiar  circumstance  that,  on  account  of  the  small  volume  of  lung- 
tissue  at  the  border  of  the  lungs,  the  resonance  of  the  lungs  imme- 
diately over  the  borders  has  very  slight  intensity,  a  relatively  deadened 
sound.  We  percuss  from  the  lung  toward  the  liver  with  strong  or  mod- 
erately strong  strokes,  and  find,  say  in  the  mammillary  line  at  the 
fifth  rib,  a  strong  relatively  deadened  sound  which  the  beginner  is 
inclined  to  regard  as  absolute  liver-dullness.  But  this,  as  has  been 
said,  corresponds  with  the  thinning  of  the  lungs  at  the  lower  border. 
In  this  way  a  zone  of  relative  dullness  manifests  itself  over  the  whole 
of  the  lower  border  of  the  right  lung,  except  close  to  the  spine  behind, 
and  in  a  similar  but  somewhat  smaller  zone  the  heart-dullness  bows 
round  and  to  the  left ;  this  is  the  (incorrectly)  so-called  relative  liver- 
and  relative  heart-dullness,  as  indicated  by  the  light  shading  in  Figs. 
22  and  23.  Also,  sometimes,  there  is  such  a  relative  dullness  over 
the  lung-spleen  boundary.  It  does  not  exist  over  the  lung-stomach 
boundary,  because  here,  by  moderate  percussion,  the  coincident  sound 
of  the  stomach  causes  a  low  tympanitic  sound. 

These  zones  are  diagnostically  important  only  in  isolated  cases,  and 
they  have  nothing  to  do  with  enlargement  of  the  heart,  liver,  or  spleen. 

In  order  to  avoid  deception  by  these  conditions,  when  determining 
the  boundaries  it  is  necessary  to  take  care : 

1.  To  percuss  lightly  in  determining  the  boundaries  of  the  lungs. 

2.  To  mark  the  lung-heart  and  the  lung-liver  boundary,  that  is 
the  border  of  the  lungs  where  the  relative  dullness  passes  into  abso- 
lute dullness,  or,  in  other  words,  where,  in  percussing  from  the  lungs 
toward  the  heart  and  the  liver,  the  dullness  begins  to  be  so  marked 
that  it  no  longer  increases. 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.  125 

On  the  average,  that  is,  in  middle  life,  we  thus  find  (compare  Figs. 
22  and  23)  :  the  lung-liver  boundary  in  the  mammillary  line  at  the 
sixth,  in  the  middle  axillary  line  at  the  eighth,  in  the  scapulary  line 
at  the  tenth  rib  ;  tlie  lower  border  of  the  left  lung :  in  general  as  high 
as  the  right  only  in  the  mammillary  line  at  the  lower  border  of  the 
sixth  rib ;  the  lung -heart  boundary :  at  the  fourth  rib  and  more  or 
less  just  without  the  parasternal  line  ;  the  upper  limits  of  the  apices  of 
the  lungs:  three  to  five  cm.  above  the  clavicle. 

Differences  by  reason  of  age.  In  children,  the  lower  border  of  the 
lungs  is  from  a  half  to  a  whole  intercostal  space  higher ;  in  old  per- 
sons, it  is  that  much  lower  (Weil).  There  is  a  like  difference  as 
regards  the  lung-heart  boundary.  That  is,  the  lungs  increase  with 
the  years,  as  compared  with  other  organs. 

Displacement  of  lower  border  of  the  lungs  is  manifest  by  percussion : 

1.  In  deep  inspiration  and  expiration  (active  mobility) :  in  the  mid- 
dle axillary  line  the  lower  border  sinks  with  deepest  inspiration  about 
three  to  four  cm. ;  in  the  mammillary  and  scapular  lines  about  two  to 
three  cm. ;  in  deepest  expiration  it  rises  up  not  quite  so  much  above 
the  average  location  (Weil).  With  deep  inspiration,  at  the  incisura 
cardiaca  the  lung  moves  so  as  quite  to  cover  the  heart ;  and  it  may 
even  entirely  obscure  the  heart  dulness. 

2.  In  change  of  position  (passive  mobility) :  when  lying  upon  one 
or  the  other  side  the  lower  border  of  the  lung  of  the  opposite  side 
moves  down  as  much  as  three  to  four  cm.  (Grerhardt,  Salzer,  Weil). 

3.  Abnormal  Sound  over  the  Lungs.    Abnormal  position  of  the 

border  of  the  lungs. 

A.  Dullness  :  Deadened  Resonance. — In  order  not  to  overlook 
slight  deadening  we  must  remember  what  was  said  upon  comparative 
percussion  on  page  124 ;  if  the  comparison  with  the  opposite  side  is 
inadmissible,  as  when  both  sides  are  diseased,  then  the  comparison 
is  made  with  the  adjacent  parts  upon  the  same  side,  bearing  in  mind 
the  normal  regional  differences  of  intensity  of  sound. 

Thus,  in  disease  of  both  apices  we  sometimes  recognize  the  dead- 
ness  of  the  apex  to  be  less  affected  by  comparing  the  resonance  over 
the  latter  with  the  percussion-resonance  a  little  lower  down  ;  remem- 
bering that  normally  the  resonance  over  the  first  and  second  inter- 


126  SPECIAL  DIAGNOSIS. 

costal  spaces  must  be  clearer  than  in  the  supraclavicular  space,  and 
clearer  than  over  the  third  intercostal  space. 

But  also,  without  further  consideration,  we  must  not  designate  every 
deadness  as  due  to  an  internal  organ,  but  consider  the  deadening 
influence  of  a  sharply-bowed  rib,  etc.  Slight  deadening^  without  any 
other  pathological  evidence,  especially  over  the  apices,  is  to  be  given 
value  with  very  great  caution. 

(a)  Resonance  is  deadened  by  the  development  of  airless  tissue  in  the 
lungs  either  by  condensation  or  by  solid  new  formations  in  them. 

In  croupous  ^pneumonia  the  lung-tissue  in  the  height  of  the  disease  is 
in  the  stage  of  hepatization.  Generally  in  a  large  region  it  is  completely 
deprived  of  air  through  the  filling  of  the  alveoli  with  inflammatory 
exudation.  An  intense  deadening  is  coextensive  with  this  condition. 
It  seldom  becomes  absolutely  deadened  like  the  thigh-sound,  but  there 
can  generally  be  recognized  a  slight  tympanitic  tone.  The  feeling  of 
resistance  is  generally  likewise  correspondingly  increased,  but  not  so 
much  as  is  the  case  with  a  pleuritic  exudation, 

Thigh-dulness  and  very  marked  feeling  of  resistance  may  exist  Avith 
croupous  pneumonia  if,  besides  the  lung-tissue,  the  bronchial  tubes  of 
that  part  of  the  lung  are  likewise  completely  filled  with  the  exudation 
("massive  pneumonia  "),  or  if  the  croupous  pneumonia  is  complicated 
with  a  large  pleuritic  exudation,  which  is  then  almost  always  behind 
and  low  in  the  chest.  The  extent  of  the  deadening  in  croupous  pneu- 
monia very  frequently  corresponds  with  a  lobe  of  the  lung,  because 
of  its  being  a  lobar  pneumonia,  or  there  is  evidence  of  an  enlargement 
of  the  lobe  in  all  directions  (the  inflammatory  exudation  spreads  out 
to  a  considerable  extent).  Often,  therefore,  in  this  disease  we  may 
recognize  the  boundaries  of  the  lobe  in  the  figure  of  the  area  of  dead- 
ening, or  the  boundaries  which  correspond  to  the  tracing  of  the  lobe 
enlarged  in  all  directions.  The  infiltrated  part  of  the  lung  may,  how- 
ever, be  also  smaller,  especially  on  the  surface  of  the  lungs,  occupying 
so  small  an  extent  as  not  to  cause  any  recognizable  deadening. 
Auscultation  (which  see)  here  leads  to  a  conclusion  sooner  than  per- 
cussion. 

In  the  neighborhood  of  an  infiltration  the  resonance  is  generally 
abnormally  loud  and  deep,  even  slightly  tympanitic  (compare  what  is 
said  of  croupous  pneumonia  under  B.  Tympanitic  Sound). 

Since  the  infiltrated  lobe  of  the  lung  is  somewhat  larger  than 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.        127 

normal,  sometimes  in  pneumonia  of  the  whole  lower  lobe  deadness 
will  be  found  posteriorly  as  far  up  as  the  apex  without  the  apex  being 
involved.  Percussion  upon  the  front  of  the  chest  then  yields  a  very 
loud,  deep  sound  over  the  upper  part  of  the  upper  lobe.  Further,  for 
the  same  reason,  in  pneumonia  of  the  left  lower  lobe  the  lower  borders 
of  the  deadness  may  overstep  the  region  of  the  normal  boundaries  of 
the  lungs,  as  the  marking  out  of  the  lung-stomach  boundary  then 
shows  that  the  so-called  " halfmoon-shaped  space"  is  somewhat 
smaller.     (See  under  Digestive  Apparatus.) 

Also  in  catarrhal  or  lobular  pneumonia  and  tuberculosis  (in  the 
so-called  infiltrated  tuberculosis  of  a  larger  part  of  the  lungs)  there 
may  be  an  extended  thickening  and  a  corresponding  deadening. 
Often,  indeed,  there  are  pathological  deposits  so  small  that  their 
presence  is  not  revealed  by  percussion ;  but  though  widely  scattered, 
they  are  interspersed  with  points  still  containing  air  and  hence  give  a 
clear  sound.  Then,  because  the  tissue  of  the  parts  still  remaining 
normal  is  somewhat  lax,  the  resonance  is  often  tympanitic.  Or,  the 
latter  sound  is  mingled  with  that  of  deadness  from  the  infiltrated  parts 
— the  tympanitic  deadened  sound. 

In  tuberculosis  of  the  apices  of  the  lungs  there  is,  at  the  beginning, 
in  very  slight  measure,  a  mingling  of  thickened  parts  with  tissue  con- 
taining air,  but  relaxed ;  hence  the  resonance  in  the  beginning  over 
the  diseased  apex  is  very  often  tympanitic  or  tympanitic-deadened,  in 
comparison  with  the  healthy  apex.  Moreover,  there  is  early  retraction 
of  the  upper  boundary  of  the  apex  upon  the  afifected  side.  (See  under 
Diminution  of  the  Boundaries  of  the  Lungs.) 

Large  hemorrhagic  infarctions  and  sections  of  the  lungs  compressed 
even  to  the  point  of  not  containing  any  air,  as  from  pleuritic  exuda- 
tions, tumors,  and  large  pericardial  exudations,  may  likewise  give  a 
deadened  sound.  Finally,  it  is  conceivable  that  solid  tumors  of  the 
lungs  (sarcoma,  carcinoma)  produce  the  same  effects  in  case  they  lie 
upon  the  surface  or  attain  to  a  certain  size. 

(6)  Resonance  is  deadened  by  the  presence  of  a  deadening  medium 
over  the  lungs — that  is,  between  it  and  the  percussing  finger. 

Most  important  of  these  is  pleuritic  exudation.  Generally,  this  first 
appears  low  down  posteriorly  in  the  complementary  space  and  above 
it,  and  if  it  amounts  to  as  much  as  400  cubic  cm.  it  may  even  be 
recognized  by  light  percussion.     Corresponding  with  the  increase  of 


128  SPECIAL  DIAGNOSIS. 

the  exudation  the  area  of  deadness  will  gradually  become  more 
extensive ;  its  limits  ordinarily  correspond  with  a  fluid  surface 
which,  while  the  patient  is  in  the  posture  most  frequently  assumed,  is 
somewhat  horizontal ;  that  is  to  say,  in  bedridden  patients  the  fluid 
levels  itself  high  up  on  the  posterior  wall  of  the  thorax,  and  the 
limits  on  the  sides  and  in  front  drop  off  sharply ;  while  with  people 
who  are  much  out  of  bed,  or  may  still  be  at  work,  the  fluid  stands 
equally  high  in  front  and  at  the  back  of  the  chest.  When  the  efi'usion 
is  very  large  the  deadness  may  extend  even  to  the  apex,  both 
anteriorly  and  posteriorly.  It  quickly  becomes,  with  considerable 
effusion,  an  absolute  deadenino;  and  with  the  most  marked  feelino;  of 
resistance. 

Corresponding  with  the  increase  of  the  fluid  the  lung  becomes  lax 
in  an  ever-increasing  area,  since  it  may  then  follow  its  elastic  trac- 
tion ;  immediately  over  the  fluid  it  gives  deadness,  and  when  there 
is  a  large  exudation,  where  at  least  there  is  ordinarily  left  a  district 
with  clear  sound,  namely,  high  in  front,  it  yields  an  abnormally 
loud  and  deep,  or  a  tympanitic  sound,  sometimes  cracked-pot  sound 
(see  page  134).  A  very  large  exudation  may  even  compress  the 
lung  to  such  a  degree  as  to  expel  all  air. 

When  there  is  a  certain  amount  of  exudation  its  weight  presses 
upon  the  diaphragm,  increases  the  affected  pleural  cavity  toward  the 
side,  presses  out  the  side  of  the  thorax  (see  above),  and  pushes  the 
mediastinum  and  the  heart  over  toward  the  sound  side  (see  Displace- 
ment of  the  Heart).  The  downward  pressure  of  the  diaphragm  in 
cases  of  pleurisy  of  the  right  side  is  recognized  by  the  liver  being 
lower  (see  Percussion  of  the  Liver).  In  pleurisy  of  the  left  side,  it 
may  directly  be  made  out  by  locating  the  upper  boundary  of  the  so- 
called  "  halfmoon-shaped  space." 

When  the  pleural  surfaces  directly  over  the  exudate  are  glued 
together,  then  in  change  of  position  of  the  patient  the  pleuritic  exuda- 
tion is  not  movable,  and  the  boundaries  of  the  deadness  are  therefore 
not  changeable ;  not  infrequently  the  exudation  is  entirely  "  capsu- 
lated ' '  by  the  adhesion  of  the  pleural  surfaces.  If  the  exudation  is 
reabsorbed,  then  the  evidences  of  expansion  and  of  displacement,  on 
the  one  hand,  and  the  deadness  (and,  indeed,  according  to  its  extent, 
likewise  its  intensity),  on  the  other  hand,  steadily  disappear.     Often 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.        ]  29 

the  upper  border  of  deadness  then  shows  as  a  bowed  line  with  its 
convexity  upward  (Damoiseau's  curve). 

If  a  new  pleuritic  exudation  takes  place  between  pleural  surfaces 
already  adherent  from  a  former  attack,  then,  of  course,  it  remains 
confined  within  the  space  thus  prepared — "■  encapsulated,  circumscribed 
pleurisy."  The  boundaries  of  the  exudation  may,  in  these  cases,  take 
a  very  varying  course. 

Hydrothorax  practically  gives  rise  to  similar  appearances ;  but  it 
is  generally  on  both  sides,  yet  not  infrequently  with  a  very  different 
amount  upon  the  two  sides.  Further,  hydrothorax  always  shows  in 
change  of  position,  although  only  after  a  certain  time,  a  change  of  its 
relation  to  the  thorax  in  such  a  way  that  it  tends  to  take  possession 
of  the  part  of  the  thorax  that,  for  the  time  being,  is  the  lowest; 
accordingly,  there  is  what  may  be  called  a  passive  mobility  of  the 
boundaries  of  deadness. 

Serous  or  purulent,  or  ichorous,  effusion  into  the  pleural  cavity  com- 
plicating pneumothorax  (sero-,  pyo-pneumothorax)  is  distinguished 
from  the  above  by  its  mobility  with  the  change  of  posture.  It  be- 
haves like  the  water  in  a  bottle  when  the  position  of  the  latter  is 
changed ;  in  every  situation  the  fluid  maintains  a  horizontal  surface, 
and  occasions  at  the  same  time,  Avith  every  change  of  place  or  location 
of  the  thorax,  a  prompt  variation  of  the  upper  boundaries  of  the 
deadness. 

.  Further,  a  deadening  of  the  resonance  is  occasioned  by  the  thick- 
ening of  the  "pleura,  which  either  remains  after  an  exudative  pleuritis 
or  in  conjunction  with  processes  slowly  going  on  in  the  lungs.  The 
latter  is  the  case  very  frequently  in  tuberculosis  of  the  apices  of  the 
lungs ;  marked  deadening,  appearing  early  in  the  beginning  of  the 
disease,  is  generally  caused  by  pleural  thickening.  The  intensity  of 
the  deadness  is  determined  by  the  amount  of  the  thickening ;  it  may 
even  become  like  thigh-deadness.  The  feeling  of  resistance  is  generally 
very  markedly  increased ;  with  very  thick  deposit  this  is  positive. 
Tumors,  as  a  matter  of  course,  likewise  cause  deadening.  This  latter 
deadening  generally  exhibits  an  irregular  boundary,  if  it  is  not,  as  is 
rarely  the  case,  complicated  by  pleuritic  exudations. 

It  is  sometimes  very  difficult  to  distinguish  between  a  thickened 
pleural  surface  and  a  portion  of  pleural  exudation  left  behind  with 
moderate  thickening ;  this  question  often  especially  arises  where  the 


130  SPECIAL  DIAGNOSIS. 

deadness  is  low  down  posteriorly.  In  arriving  at  a  decision  the  first 
thing  to  consider  is  whether  there  is  expansion  or  contraction,  or 
whether  there  is  a  deep  or  a  high  position  of  the  diaphragm. 

But  here,  as  well  as  in  the  often  very  diificult  differential  diagnosis 
between  pleural  exudations  and  tumors,  as  of  the  lungs,  pleura,  or 
chest-wall,  the  application  of  the  explorative  puncture  is  the  best 
means  of  deciding. 

Finally,  the  resonance  of  the  thorax  is  deadened  by  all  processes 
in  the  chest-wall  which  lead  to  its  being  thickened — tumors,  peri- 
pleuritis, oedema. 

The  second  quality  of  sound  tvhich  is  found  over  diseased  lungs  is 

B.  Tympanitic  Sound. — (a)  It  occurs,  pathologically,  if  the  lung 
is  in  a  state  of  elastic  equilibrium  :  we  know  that  this  condition 
is  a  consequence  of  retraction  of  the  lung :  with  large  pleuritic 
exudation  as  well  as  shrinking  in  connection  with  pleurisy ;  further, 
in  all  other  affections  of  the  chest  which  decrease  its  capacity.  Hence 
tympanitic  resonance  exists  over  the  lungs  in  the  neighborhood  of 
tumors  of  all  kinds ;  sometimes  in  the  neighborhood  of  the  heart  in 
exudative  pericarditis,  more  rarely  in  hypertrophy  and  dilatation  of 
the  heart ;  lower  in  the  thorax  :  in  diaphragmatic  pleurisy ;  in  high 
position  of  the  diaphragm  from  subphrenic  tumors,  abscesses,  etc.; 
and  in  general  peritonitis,  general  distention  of  the  abdomen  from 
ascites,  tumors,  etc. 

We  may  also  think  of  the  same  condition  of  approaching  equilibrium 
of  elasticity  as  arising  from  relaxation  of  the  lung-tissue  (Weil) ;  and 
this  will  explain  the  tympanitic  resonance  that  exists  with  croupous 
pneumonia  in  the  stage  of  engorgement  and  resolution ;  over  many 
small  catarrhal-pneumonic  and  tubercular  deposits.,  since  the  inter- 
vening tissue  containing  air  has  become  lax ;  and  finally,  in  oedema 
of  the  lungs. 

{b)  In  consequence  of  marked  shrinking  and  thickening  of  the 
lung,  in  strong  percussion  of  the  supraclavicular  fossa,  it  arises  from 
the  trachea,  while  in  percussing  the  first  or  second  intercostal  space 
it  arises  from  this  or  the  primary  bronchus,  directly  from  the  percus- 
sion-blow, and  so  the  broncho-tracheal  column  of  air  is  put  in  vibra- 
tion ;    thus  arises  a  peculiar  change  of  sound    in    the  trachea,  the 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.        l^i 

sound  with  the  mouth  open  being  more  distinctly  tympanitic  and 
higher  (Williams's  tracheal  tone). 

{c)  Over  cavities  within  the  lungs,  caverns  (vomicce). 

We  may  have  here,  according  as  the  cavity  does  or  does  not  com- 
municate with  the  outer  air  by  means  of  a  pervious  bronchial  tube, 
the  open  or  the  closed  tympanitic  resonayice.  In  the  former  case  the 
sound  is  under  all  circumstances  more  distinctly  tympanitic  and  also 
more  intense ;  in  the  latter  case,  on  the  other  hand,  much  less  distinct 
and  weaker,  all  the  more  since  we  must  assume  that  the  cavities, 
because  they  lie  in  the  thorax,  have  more  or  less  stiff  walls,  and  since 
the  rigidity  of  the  wall  with  the  cavity  closed  hinders  the  condition 
that  causes  the  tympanitic  sound. 

How  large  the  cavity  must  be  in  order  to  give  a  tympanitic  sound 
it  is  not  possible  exactly  to  state,  since  besides  the  size,  the  situation 
of  the  cavity  (whether  parietal  or  deep),  the  amount  of  fluid  secretion 
it  contains,  its  walls  (whether  smooth  and  vibratory),  the  condition  of 
the  surrounding  lung-tissue,  and  finally  the  vibratory  capacity  of  the 
given  thorax  must  also  be  taken  into  consideration.  Generally,  cavi- 
ties occurring  in  the  apices  from  tuberculosis  exhibit  more  distinct 
ph^'sical  characteristics  than  cavities  in  the  lower  portions  of  the 
lungs,  which  frequently  are  of  the  nature  of  bronchiectasis,  since 
the  former,  even  when  of  moderate  size,  must  reach  to  the  surftice  of 
the  lungs,  and  generally  have  tliickened  walls.  Cavities  as  large  as 
a  walnut  in  the  upper  parts  of  the  lungs  generally  give  a  distinctly 
tympanitic  resonance. 

If  the  cavity  is  very  large  with  relatively  smooth  walls  a  metallic 
tone  is  added  to  the  tympanitic  resonance. 

If  the  cavity  is  covered  by  thickened  lung-tissue  or  with  thickened 
pleura  (this  very  frequent)  then  the  sound  becomes  tympanitic-dead- 
ened ;  if  by  a  very  thick  layer  of  airless  tissue,  absolutely  deadened. 

Temporarily  marked  filling  of  the  cavity  with  secretion  deadens  the 
tympanitic  sound  also,  sometimes  even  to  absolute  deadening;  further, 
the  sound  becomes  temporarily  indistinctly  tympanitic  and  deadened- 
tympanitic  if  a  bronchus  connecting  with  it,  otherwise  open,  becomes 
closed  (with  secretion  or  from  dipping  belovf  the  fluid  contents  of  the 
cavity). 

Under  different  conditions  tympanitic  sound  over  a  cavity  may 
change  its  pitch : 


132  SPECIAL  DIAGNOSIS. 

1.  The  so-called  simple  Wintrich's  change  of  sound.  The  tym- 
panitic sound  becomes  louder,  more  distinctly  tympanitic,  and  higher, 
if  the  patient  opens  the  mouth  wide  (and,  what  is  desirable,  at  the 
same  time  protrudes  the  tongue  a  little).  This  can  only  occur  over 
those  cavities  that  freely  communicate  with  the  broncho-tracheal 
column  of  air. 

We  percuss,  not  too  strongly,  while  the  patient  lies  ■  or  stands 
quietly  and  alternately  opens  and  closes  the  mouth ;  but  it  is  neces- 
sary for  the  patient  to  breathe  as  superficially  as  possible,  or  we  must 
compare  the  sound  in  the  same  stage  of  the  breathin.g,  since  the  sound 
also  sometimes  changes  its  pitch  according  to  the  stage  of  the  breath 
(compare  under  4.  Respiratory  change  of  sound). 

The  explanation  of  this  symptom,  as  of  the  tracheal  change  of 
sound  which  is  exactly  similar,  is  that  it  is  from  the  change  of  con- 
sonance of  the  mouth-throat  cavity. 

This  Wintrich's  change  of  sound  may  also  occur  over  cavities  in 
such  a  way  that  the  sound  with  the  mouth  closed  is  markedly 
deadened,  with  only  a  trace  of  tympanitic  sound  (especially  with 
marked  callous  formations  over  the  cavity),  and  only  with  the  mouth 
open  does  the  sound  become  tympanitic  (at  the  same  time  becoming 
louder  and  noticeably  higher). 

I  would  hke,  therefore,  in  opposition  to  Weil,  to  insist  that  we 
ought,  if  there  is  only  a  slight  possibility  of  the  existence  of  a 
cavity,  and  also  in  the  case  of  tympanitic  sound  slightly  distinct,  even 
indistinct,  with  dulness,  to  apply  the  test  of  Wintrich's  change  of 
sound. 

It  is  very  easy  to  confound  the  simple  Wintrich's  change  of  sound 
with  Williams's  tracheal  tone.  We  should  take  notice  :  (1)  Whether 
there  is  very  marked  contraction,  when  it  is  much  more  likely  to  indi- 
cate change  of  sound  than  Williams's  tracheal  tone.  (2)  Whether  in 
order  to  cause  the  change  of  sound  only  weak  percussion  (cavity)  or 
strong  percussion  (trachea  or  bronchus)  is  required.  (3)  Whether 
there  are  other  symptoms  of  a  cavity. 

Simple  Wintrich's  change  of  sound  points  with  greater  probability 
to  a  cavity.  But  its  value  as  an  indication  is  diminished  by  the 
above-mentioned  possibility  of  being  confounded  with  Williams's 
tracheal  tone. 

2.  Interrupted  Wintrich's  change  of  sound  (Gerhardt,  Moritz).    It 


EXAMINATION  OF  THE  RESPIRATOR}'  APPARATUS. 


13-3 


is  distinguished  from  the  simple  in  that  in  some  positions  of  the  bodj 
it  is  plain,  in  others  it  is  indistinct  or  is  wanting.  The  explanation 
of  this  is  that  in  one  position  the  bronchus  leading  to  the  cavity  is 
open,  while  in  the  other  it  dips  into  the  secretion  in  the  cavity  and  so 
is  closed.  In  this  way  the  tracheal  change  of  sound  cannot  possibly 
be  interrupted 

This  change  of  sound  is  very  rarely  met  with,  but  it  is  to  be 
regarded  as  a  positive  sign  of  a  cavity. 

3.  Gferhardt's  change  of  sound.  A  tympanitic  sound  changes  its 
pitch  if  the  patient  changes  his  posture  (upright,  dorsal,  side  position); 
and  sometimes,  if  the  patient  changes  from  the  dorsal  to  the  upright 


Fig.  2-i. 


Oerhardt's  change  of  sound  — Schematic  rejiresentation  of  the  behavior  of  the  contents 
of  a  cavity  with  a  change  of  position  of  the  body  of  the  patient. 

position,  the  sound  becomes  deadened-tympanitic  or  absolutely  dead- 
ened over  the  lower  part  of  the  cavity,  because  in  this  position  the 
fluid  contents  of  the  cavity  come  into  contact  with  the  chest- wall. 

Gerhardt's  change  of  sound  may  take  place  over  communicating,  as 
well  as  over  closed,  cavities.  The  change  of  pitch,  in  case  the  cavity 
is  open,  may  have  very  different  causes,  which  we  will  not  discuss  here. 
In  closed  cavities  it  is  really  due  to  a  change  in  the  tension  of  the 
chest  (and  cavity  ?)  wall,  perhaps  also  to  a  change  in  the  size  of  the 
part  of  the  cavity  containing  air — a  change  caused  by  different  loca- 
tion of  the  secretion.     (See  Figs.  24  and  25,  from  WeiVs  Handbook.) 

Gerhardt's  change  of  sound  is  in  every  form  an  almost  certain 
symptom  of  a  cavity,  but,  like  the  former,  it  is  very  rare. 

4.  Friedreich's  or  the    respiratory    change  of  sound:    the  sound 


134  SPECIAL  DIAGNOSIS. 

l)ecomes  higher  at  ihe  height  of  a  deep  inspiration.  This  occurs  not 
alone  over  cavities,  but  may  be  observed  in  any  case  of  tympanitic 
sound  over  the  lungs.  It  depends  upon  the  increased  tension  during 
inspiration  of  the  chest-wall  and  lung-tissues,  likewise  of  the  wall  of 
the  cavity. 

It  does  not  have  diagnostic  significance.  But  it  is  important  to 
know  it  in  order  that  we  may  not  be  misled  by  it  in  the  examination 
of  other  changes  of  sound ;  therefore,  we  ought  in  testing  this  to 
observe  the  rule  to  percuss  during  very  superficial  breathing,  or  still 
better  always  to  percuss  at  the  same  stage  of  the  breathing,  as  has 
been  said  above. 

{d)  Finally,  the  tyinpanitic  sound  occurs  in  very  rare  cases  in 
pneumothorax  and  sometimes  entirely  in  cases  that  have  permanent 
and  completely-open  fistulse  ;  this  "  open  "  pneumothorax  is  generally 
circumscribed.  In  pneumothorax  the  tympanitic  sound  may  some- 
times exhibit  Wintrich's  change,  since  the  physical  conditions  upon 
which  it  depends  are  also  present,  as  in  large  communicating  cavities  : 
open  communication  of  an  air-space  with  the  broncho-tracheal  column 
of  air.     Here  we  have  also  metallic  tone  (see  p.  135). 

Oracked-ijot  sound  (britit  de  jyot  fele).  It  seems  that  this  is  the 
most  suitable  place  to  describe  this  phenomenon,  which,  Avhile  very 
surprising  and  remarkable,  is  of  very  subordinate  diagnostic  sig- 
nificance. It  consists  of  a  peculiar  click  ("  clinking  of  coin  "  or 
"trembling"),  which  sometimes  accompanies  the  clear  sound  and 
indeed  generally  the  tympanitic,  more  rarely  the  clear,  nun-tympanitic. 
It  corresponds  to  the  noise  which  occurs  when  wo  strike  a  cracked 
plate  or  pot,  or  when  we  hold  the  palms  of  the  hands  together  lightly 
and  then  strike  them  upon  the  knee.  It  occurs  in  the  thorax  if 
an  instantaneous  current  of  air  of  a  given  force  is  driven  from  the 
lungs  against  the  larynx  by  the  percussion-stroke,  or  if  during  expira- 
tion a  stream  of  air  flowing  outward  is  for  a  moment  suddenly  sharply 
arrested.  This  symptom  requires  strong  percussion,  yielding  thorax, 
and  thin  covering  (generally  in  front  superiorly,  and  also  below 
posteriorly).  It  occurs  sometimes  in  normal  cases,  especially  in 
children. 

Pathologically  it  occurs: 

1.  Over  large  parietal  cavities,  here  often  remarkably  intense. 

2.  In  pneumothorax  with  open  fistula,  especially  if  circumscribed. 


EXAMINATION  OF  THE  RESPIRATOR V  APPARATUS.        135 

3.  Ov&c  pnemaonic  deposits. 

4.  Over  retracted  lung  tissue,  especially  above  large  pleuritic  exuda- 
tions (high  in  front),  rarely  in  the  neighborhood  of  thickened  portions 
of  lung. 

This  phenomenon  is  always  more  distinct  if  we  percuss  during 
expiration ;  very  often,  especially  in  case  of  cavity  and  open  pneumo- 
thorax, it  becomes  louder  by  opening  the  mouth. 

As  above  remarked,  this  symptom  has  almost  no  diagnostic  meaning, 
since  it  is  present  with  such  varying  conditions. 

The  noise  is  caused  by  a  swift  current  of  air  striking  at  a  narrowed 
point;  this  happens  at  the  glottis,  in  a  cavity  at  the  mouth 'of  a 
bronchus,  and  at  the  puncture  in  the  pleura  in  case  of  pneumo- 
thorax. Sometimes  a  rattling  sound  is  mingled  with  the  trembling 
("  the  moist  cracked-pot  sound"). 

C.  Abnormally  Loud  and  Deep  Sound.- — This  occurs  : 

1.  In  severe  emphysema  of  the  lungs,  designated  as  "  band-box 
note"  (Biermer). 

2.  In  decreased  tension  of  lung  tissue  above  a  pleuritic  exudation  : 
a  zone  of  this  abnormal  sound  lies  just  above  the  line  of  deadness  pro- 
duced by  the  exudation  in  the  neighborhood  of  pneumonic  thickening 
— as  anteriorly  in  pneumonia  of  a  whole  lower  lobe ;  sometimes  in  the 
neighborhood  of  the  heart  in  pericarditis  exudativa,  but  also  with 
dilatation  and  hypertrophy  ;  likewise,  and  especially,  in  the  neighbor- 
hood of  encroaching  tumors,  and  with  a  high  position  of  the  diaphragm 
consequent  upon  abdominal  affections. 

As  was  said  before,  in  most  of  these  cases,  if  the  tension  of  the 
lung-tissue  is  very  considerable,  tympanitic  resonance  may  arise  (see 
p.  130). 

3.  With  pneumothorax.  Here  the  sound,  in  consequence  of  the 
strono"  tension  of  the  chest-wall,  is  almost  always  non-tympanitic, 
loud  and  deep.  Only  (a  rare  case)  in  open  pneumothorax,  especially 
if  it  be  circumscribed,  is  tympanitic  sound  sometimes  met  with  (see 
p.  134). 

This  abnormally  loud  and  deep,  even  tympanitic  sound  of  pneumo- 
thorax gives  almost  regularly  the  metallic  sound,  only  seldom  recog- 
nizable, however,  by  the  ordinary  methods  of  percussion,  but  very 
admirably  by  the  rod-pleximeter  percussion  described  by  Heubner. 


136  SPECIAL  DIAG-NOSIS. 

3Iode  of  application.  Rod-pleximeter  percussion  is  best  conducted 
bj  two  examiners.  One  strikes  with  the  handle  of  the  percussion- 
hammer,  or  with  a  pencil  upon  a  pleximeter;  the  other  auscults 
the  thorax.  If  both  manipuhite  over  a  pneumothoracic  cavity  the 
second  hears  the  strokes  as  the  finest  metalHc,  generally  a  silvery, 
clear  rino;ino;. 

This,  moreover,  is  sometimes  also  observed  with  very  large  and 
smooth-ivalled  cavities  with  tliin  covering.  With  pneumothorax 
accompanied  with  fluid  (pyo-,  seropneumothorax)  the  metallic  sound, 
almost  without  exception,  changes  its  pitch  with  the  change  of  posi- 
tion ;  in  sitting  up  it  is  generally  deeper,  but  sometimes  also  higher 
(Biermer's  change  of  sound).  If  the  effusion  is  so  large  as  entirely, 
or  almost  entirely,  to  fill  the  pleural  cavity  of  course  the  metallic  sound 
disappears. 

It  will  be  mentioned  in  the  appropriate  sections  that  this  metallic 
ringing  in  pneumothorax  not  only  accompanies  such  an  artificially 
created  noise,  but  also  may  be  present  with  rhonchus,  respiratory 
sound,  and  heart-sound. 

D.  Changed  Condition  (and  Diminished  Power  op  Displace- 
ment) OF  THE  Boundaiues  OF  THE  LuNGS. — (a)  Extension  of  the 
boundaries  of  the  lungs  takes  place  in  emphysema:  the  lower  borders 
usually  move  sidewise  and  deeper,  both  front  and  back,  in  the  most 
marked  cases.  The  raammillary  line  will  be  at  the  eighth  rib,  the 
axillary  line  at  the  tenth,  the  scapular  line  at  the  eleventh  or  twelfth. 
Heart  deadness  may  also  or  quite  disappear,  from  the  expanded 
lung  lying  over  it  from  the  side.  At  the  apices  of  the  lungs  some- 
times a  slight  enlargement  of  the  lungs  may  be  made  out ;  in  rare 
cases  even  expansion  of  the  apices  may  likewise  take  place  (as 
after  whooping-cough  in  children).  "Relative  1  iver- dullness  "  and 
"heart-dullness"  is  very  small ;  simultaneously  with  the  expansion, 
the  lung  loses  its  power  of  displacement,  both  active  and  passive, 
even  past  recognition. 

One-sided  downward  movement  of  the  boundary  of  the  lung  occurs 
in  vicarious  emphysema,  but  the  capacity  to  change  its  boundaries  is 
preserved  in  this  case. 

Apparent  one-sided  expansion  of  the  boundary— tha,t  is  to  say,  the 
appearance  of  a  clear  sound  upon  one  side  quite  beyond  the  normal 
boundary  of  the  lung — takes  place  in    diffuse  pneumothorax :   the 


EX  A  MIX  A  TION  OF  THE  RES  PI R  A  TOR  V  A  PPA  RA  TUS.        1 3  7 

lower  border  of  the  clear  sound  is  sometimes  met  with  even  deeper 
than  in  emphysema ;  this  border  is  immovable,  and  always  very 
sharply  defined.  The  side  of  the  thorax  is  expanded,  the  heart  and 
also  liver  are  displaced,  or  the  tympanitic  sound  of  the  "  half-moon- 
shaped  ''  space  is  replaced  by  the  sound  of  pneumothorax.  Displace- 
ment of  the  mediastinum  in  right-sided  pneumothorax  is  generally 
distinctly  recognized  by  the  change  of  sound  between  it  and  the  left 
lung  (the  boundary-line  lies  to  the  left  of  the  upper  part  of  the 
sternum). 

{h)  Diminished  volume  of  the  lungs  is  shown  by  the  lower  boundaries 
of  the  lungs  being  higher  than  normal  on  both  sides,  by  the  diaphragm 
being  pressed  up  from  below  or  from  its  being  paralyzed ;  one-sided 
diminution,  by  shrinking  from  disease  of  the  lung  or  a  past  pleurisy. 
The  motility  of  the  borders  is  thus  diminished  or  destroyed.  The 
liver  stands  correspondingly  higher  (see  Liver),  or  the  "  half- moon- 
shaped  "  space  is  enlarged. 

Sometimes  diminution  in  size  of  an  apex  in  phthisis  manifests  itself 
by  the  deeper  position  of  the  upper  border  of  the  lung  upon  one  side. 

(c)  Diminution  of  the  motility  alone,  especially  during  respiration, 
without  change  of  the  average  condition  of  the  borders,  sometimes 
exists  low  down  posteriorly  as  the^rs^  symptom  of  pleurisy,  and  also 
as  the  only  sign  of  a  past  pleurisy,  in  which  case  it  is  noticed  along 
the  whole  lower  border  of  a  lung  or  a  part  of  the  same,  as  at  the 
heart ;  here,  also,  it  is  a  residuum  of  pericarditis  externa.  (See 
Examination  of  the  Heart.) 

Retraction  of  the  lungs  in  the  neighborhood  of  the  heart  by 
shrinking  permits  the  latter  to  come  in  contact  with  the  chest-wall 
to  a  larger  extent  than  normal ;  there  is  displacement  of  the  heart- 
border  of  the  lung  to  the  left  and  upward,  and,  hence,  hypertrophy  or 
dilatation  of  the  heart  may  at  first  be  mistaken  for  the  real  condition, 
(See  Heart.) 

On  the  other  hand,  diseased  conditions  in  the  neck  (tumors,  scars, 
etc.)  may  influence  the  position  of  the  apices,  and  thus  at  first  may 
deceive  the  inexperienced  in  leading  him  to  conclude  that  there  is 
one-sided  shrinking  of  the  lung. 


138  SPECIAL  DIAGNOSIS. 

AUSCULTATION    OF    THE    LUNGS. 

1.  History.    The  Sphere  of  Auscultation  at  the  Present  Time. 

'  It  now  appears  to  us  very  strange  that  the  idea  of  percussing  the 
body  was  only  so  lately  brought  into  medical  practice.  It  is  yet 
more  difficult  to  understand  that  methodical  auscultation  of  the  body 
is  only  a  child  of  the  most  recent  time.  It  is  true  that  Hippocrates 
heard  what  he  named  a  succussion-sound,  and  also,  no  doubt,  rattling 
and  rubbing  sounds  ;  but  to  the  two  latter  he  did  not  attach  any  great 
importance,  and  in  all  the  centuries  from  the  Greek  physician  to  the 
time  of  Laennec  no  real  attention  was  given  to  the  audible  phenomena 
of  the  healthy  and  diseased  body.  Only  a  few  voices — that  of  the 
often-mentioned  Hooke  more  than  any  other  (second  half  of  the 
seventeenth  century) — were  timidly  raised,  and  these  Avere  not  heeded. 
Only  in  consequence  of  the  discovery  and  general  consideration  of 
the  value  of  percussion  was  auscultation  developed,  and  this  by 
Laennec,  the  discoverer  of  the  stethoscope.  His  epoch-making  work 
is  called  TraitS  de  V Auscultation  mediate  et  des  Maladies  des  Poumons 
et  du  Coeur.  After  him,  Skoda,  by  critical  sifting  and  by  his  own 
efforts,  which  traced  the  new  phenomena  to  their  physical  causes, 
rendered  imperishable  service  to  this  branch  of  knowledge.  But  up 
to  the  present  time  the  work  has  still  been  going  on,  which,  in  part, 
has  made  new  discoveries,  and,  in  part,  has  investigated  the  nature  of 
what  was  already  known. 

The  sphere  of  auscultation — of  listening — in  its  widest  sense 
extends  to  all  that  we  are  able  to  take  note  of  by  the  ear,  hence,  in 
the  first  place,  to  the  voice,  cough,  noises  caused  by  breathing,  by 
mucus  in  the  upper  air-passages,  which  may  often  be  heard  in  the 
furthest  corner  of  the  sick-chamber.  But,  strictly  speaking,  ausculta- 
tion concerns  only  those  phenomena  which  the  ear  perceives,  either 
by  direct  application  to  the  body  or  which  are  brought  to  it  by  an 
instrument,  as  a  stethoscope  or  an  ear-trumpet.  These,  so  far  as  they 
refer  to  the  respiratory  apparatus,  form  the  subject  of  the  following 
section, 

2.  Methods  of  Auscultation. 

Nowadays  we  employ  both  immediate  (direct)  and  the  mediate 
(indirect)  auscultation.     In  the  first,  the  ear  is  directly  applied  to  the 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.        I39 

person  to  be  examined ;  in  the  latter,  we  employ  a  stethoscope  or  ear- 
trumpet.  While,  as  will  be  referred  to  later,  we  employ  almost  ex- 
clusively the  indirect  method  in  examining  the  heart  and  vessels,  both 
methods  are  applied  in  the  examination  of  the  respiratory  apparatus, 
and  particularly  of  the  lungs.  In  applying  both,  where  it  is  possible, 
we  must  endeavor  to  have  the  body  bare ;  in  no  case  should  the  cover- 
ing be  more  than  a  single  thickness,  and  that  should  be  as  thin  as 
possible,  and  must  be  perfectly  smooth,  [By  the  use  of  a  solid — a 
wooden  or  hard-rubber — stethoscope  it  is  not  absolutely  necessary  to 
remove  the  clothing ;  by  pressing  the  instrument  firmly  against  the 
chest  with  the  fingers  friction  of  the  clothing  is  prevented  ] 

The  application  of  the  ear  to  the  body  consists  simply  in  laying  the 
ear  lightly  over  the  particular  part  to  be  examined.  In  order  to  place 
the  ear  exactly  over  the  spot  which  we  wish  to  auscult,  it  is  well  to 
place  the  tip  of  the  index-finger  at  the  point  and  keep  it  there  until 
the  ear  is  placed  at  the  point  indicated,  when  the  finger  is  withdrawn. 
For  stethoscopic  auscultation,  almost  universally  used  in  Germany  at 
the  present  time,  preference  is  given  to  the  simple  hollow  stethoscope, 
the  tube  being  about  twelve  to  eighteen* cm.  long,  with  a  not  too  small 
ear-plate.  No  doubt  the  plate  has  this  disadvantage — unless  the 
examiner  is  sufficiently  careful — that  it  does  not  lie  smoothly  upon  the 
outer  ear;  but,  nevertheless,  it  is  the  most  suitable  form,  since  the 
stethoscope  with  hollowed  ear-pieces,  especially  those  recently  devised, 
which,  embracing  the  head  of  the  auscultator,  lie  over  the  whole  outer 
ear,  for  most  persons  have  a  most  disturbing  roar — a  disadvantage 
which  quite  outweighs  the  advantage  that,  by  increasing  the  resonance, 
it  so  well  conducts  the  noises  from  the  body ;  and  the  cone-shaped 
ear-pieces  which  are  inserted  into  the  outer  ear,  in  the  short  stetho- 
scopes with  stiff  tubes,  cannot  long  be  borne  by  the  examiner. 

These  stethoscopes  may  have  the  further  peculiarity  that  the  end 
that  rests  upon  the  body  measures,  on  the  average,  not  more  than  two 
to  five  cm.;  hence  they  conduct  to  the  ear  impressions  of  sound  from 
a  much  smaller  region  than  will  be  heard  from  by  direct  auscultation. 
They  are  made  of  various  material  (wood,  hard  rubber,  ivory),  but 
this  is  of  small  importance.  The  flexible  stethoscopes  (rubber  tubing 
instead  of  the  stiif  tube,  and  ear-cones  instead  of  the  ear-plate)  come 
less  into  use  because  it  is  difficult,  at  least  in  the  beginning  of  their 
use,  to  exclude  the  marked  noises  that  are  associated  with  them.     Of 


140  SPECIAL  DIAGNOSIS. 

the  double  stethoscopes  I  only  mention  that  of  Camman,  since  it  is 
decidedly  very  useful ;  hut  it  is  a  complicated  instrument. 

In  general  the  use  of  the  stethoscope  resembles  the  practice  of 
percussion  in  that  everyone,  especially  while  learning,  ought  always 
to  use  the  same  kind  of  instrument,  in  order  that  he  may  learn  to 
judge  correctly  of  the  auditory  impressions  which  his  instrument 
furnishes.  In  my  teaching  I  have  always  found  that  those  students 
who  each  time  they  wished  to  make  an  examination  had  to  borrow  an 
instrument  from  their  fellows  did  not  hear  anything. 

There  are  a  large  number  of  forms  of  stethoscopes,  especially  of  the 
hollow  stiff  ones,  the  separate  models  of  which  it  is  not  possible  to 
describe.  It  may  be  remarked  that  the  microphone  has  recently  been 
employed. 

P.  Niemeyer's  solid  stethoscope  with  ear-cones  (acuoxylon)  is  deci- 
dedly not  to  be  recommended;  it  has  not  proved  practical,  nt)r  are  the 
theoretical  grounds  of  its  construction  sound. 

It  is  very  important  in  the  beginning  not  to  make  pressure  with 
the  stethoscope.  Hence  it  is  advisable  to  steady  the  instrument  with 
two  fingers,  and  not  to  hold  ifin  place  Avith  the  head. 

As  was  said  above,  it  is  decidedly  to  be  recommended  in  the  exam- 
ination of  the  lungs  to  employ  both  direct  and  indirect  auscultation. 
The  former  is  here  preferable,  since  by  it  we  can  generally  listen  at 
one  time  to  a  large  region  of  the  lung ;  hence  it  is  on  the  one  hand 
more  comprehensive,  and  on  the  other  hand  furnishes  collectively 
louder  sounds.  Moreover,  in  the  examination  of  the  chest  posteriorly 
of  very  sick  patients  it  cannot  be  dispensed  with,  since  by  its  compre- 
hensiveness it  furnishes  the  means  of  conducting  the  examination 
with  the  necessary  quickness.  On  the  other  hand  the  stethoscope  is 
employed ; 

1.  Where  the  ear  cannot  be  applied,  as  over  the  supraclavicular 
spaces. 

2.  If  we  wish  to  listen  quite  separately  to  noises  existing  in  a 
narrow  limited  space. 

3.  Sometimes  from  reasons  of  delicacy,  as  over  the  female  breast. 

4.  If  the  physician  wishes  to  avoid  being  soiled,  the  risk  of  receiv- 
ing or  getting  parasitic  insects,  or  infections. 

In  a  general  examination  it  is  well  to  auscultate  after  percussing. 
After  percussing  the  front  of  the  chest,   auscultate  over  the  same 


EXAMINATION  OF  THE  RESPIRATORV  APPARATUS.        141 

region  and  then  percuss  and  auscult  the  back.  Generally  the  patient 
should  breathe  deeply ;  it  is  not  at  all  preferable  to  have  him  breathe 
very  hard  and  quickly.  Not  infrequently  we  hear  best  with  mode- 
rately deep  breathing.  Where  it  is  possible,  as  in  percussion,  sym- 
metrical parts  should  be  compared.  The  particular  points  where  it  is 
necessary  to  take  care  are  described  in  the  following  section. 

3.  Auscultatory  Signs  in  Normal  Respiration. 

1.  Sound  of  bronchial  'breathing.  If  we  auscult  the  larynx  or 
trachea  of  a  healthy  person  during  inspiration  and  expiration  we  hear 
a  loud  aspirating  sound  which  corresponds  somewhat  exactly  with  that 
we  can  make  with  the  mouth  when  we  put  it  in  position  to  pronounce 
"h"  or  "  ch  "  and  then  inspire  or  expire.  We  designate  this  sound 
as  the  laryngeal  and  tracheal,  or  by  the  collective  expression,  bron- 
chial breathing  sound.  Its  peculiarity  is  its  more  or  less  pronounced 
sharpness  {eh  or  h  sound)  and  moreover  a  somewhat  rising  pitch ; 
again,  it  is  ordinarily  somewhat  louder  (and  deeper)  in  expiration  than 
during  inspiration.  The  sound  is  formed  in  the  glottis  by  the  eddies 
which  are  here  formed  in  the  current  of  air  by  the  sudden  narrowing; 
it  is  louder  in  expiration,  because  the  rima  glottidis  is  narrower  then 
than  during  inspiration.  The  strength  and  rapidity  of  the  breathing 
have  a  great  influence  upon  the  loudness  of  the  sound. 

Besides  over  the  throat  in  front,  where  the  larnyx  and  trachea  lie 
superficially,  we  hear  this  sound  over  the  vertebra  prominens  at  the 
back  of  the  neck  in  healthy  persons  during  moderately  strong  breath- 
ing; also,  sometimes,  over  the  upper  part  of  the  sternum;  very 
frequently,  too,  in  the  interscapular  space,  and  more  plainly  upon  the 
right  than  to  the  left  of  the  median  line  (region  of  the  bifurcation). 

Bronchial  breathing  may  be  noticed  at  other  parts  of  the  thorax  at 
a  varyinof  distance  from  the  above  regions  durino;  strons;  breathing, 
especially  with  violent,  coughing  expiration.  It  is  heard  earliest  over 
the  upper  sections  of  the  chest.  There  may  be  great  individual 
differences  and  yet  be  within  the  limits  of  the  normal,  Confounding 
bronchial  breathing  with  the  diseased  conditions  to  be  mentioned  later 
will  be  avoided  by  noting  the  approximate  symmetry  of  this  breathing- 
sound,  the  condition  in  feeble  breathing,  and  also  the  result  of  the 
further  examination. 


142  SPECIAL  DIAGNOSIS. 

A  noise  which  arises  in  the  pharnyx  and  at  the  lips  of  the  person 
examined  not  infrequently  disturbs  or  deceives  the  beginner  ;  closing 
the  free  ear  is  here  recommended. 

2.  Vesicular  breathing.  In  healthy  persons  this  is  heard  -wherever 
the  lungs  lie  in  contact  with  the  chest  wall  (with  the  exception  of  in 
the  interscapular  space  ;  see  above).  It  is  of  a  very  slight  shuffling 
character,  resembling  the  sound  we  may  produce  by  placing  the  lips 
in  position  to  say  '-f "  or  "v."  The  pitch  of  this  sound  can  only  be 
approximately  recognized  (like  the  clear  non-tympanitic  sound). 

This  sound  can  only  be  heard  in  inspiration,  and  most  plainly  at 
the  end  of  inspiration.  In  a  sound  lung  expiration  has  a  very  slight 
breathing  sound  which  may  be  said  to  be  of  bronchial  character.  Not 
infrequently  it  is  wholly  imperceptible ;  sometimes,  however,  we  find 
inspiration  which  is  simply  like  a  very  much  weakened  vesicular 
inspiratory  sound. 

The  force  of  vesicular  breathing  varies  very  much.  It  is  most 
determined  by  the  strength  of  the  breathing  ;  in  very  strong  respiration 
it  is  often  so  loud  that  it  is  also  heard  over  the  organs  adjacent  to  the 
lungs,  as  over  the  heart,  liver,  and  stomach.  In  the  majority  of  healthy 
persons  the  vesicular  murmur  is  louder  upon  the  left  side  than  upon 
the  right  (Stokes).  Otherwise  the  strength  of  this  breathing  sound  is 
determined  by  the  loudness  of  the  pulmonic  sound;  over  thin  portions 
of  the  lung,  as  the  apices,  it  is  very  slight,  and  likewise  it  may  be 
weakened  by  the  thickness  of  the  covering  even  to  such  a  degree  as 
not  to  be  heard  at  all.  Moreover,  there  are  individual  differences 
which  depend  chiefly  upon  the  differences  in  the  width  of  the  glottis, 
also  on  the  elasticity  of  the  chest  on  the  one  hand  and  on  that  of 
the  lungs  on  the  other. 

Puerile  breathing  (Laennec).  The  vesicular  murmur  in  children  is 
remarkably  different  from  that  of  maturity ;  the  former  up  to  about 
the  twelfth  year  of  age  exhibits  a  remarkably  distinct,  loud  and  sharp 
vesicular  breathing  sound,  which  approaches  bronchial  breathing, 
especially  also  in  that  often  it  is  nearly  as  strong  in  expiration  as  in 
inspiration.  Generally,  also,  women  have  a  stronger  vesicular  murmur 
than  men. 

Origin.  Vesicular  breathing  sound  is  nothing  more  than  the 
bronchial  breathing  sound  as  it  is  heard  over  the  trachea  or  larynx. 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.        14^ 

as  it  is  formed  at  the  rima  glottidis  (see  above),  but  changed  by  being 
prolonged  into  the  air-containing  lung.  It  is  the  air-containing  lung 
which  causes  that  sharp  sound,  having  a  musical  pitch,  to  reach  our 
ears  so  changed  in  character.  Any  tissue  not  containing  air,  and, 
indeed,  the  lung-tissue  that  has  been  deprived  of  air  by  the  products 
of  disease,  as  "will  be  shown  below,  conducts  tl^c  bronchial  breathing 
unchanged  from  the  large  tubes  in  which  it  forms  to  the  surface  of  the 
chest,  and  so  to  the  ear;  and,  on  the  other  hand,  a  piece  of  animal 
lung  inflated,  placed  upon  the  neck,  when  auscultated  changes  the 
laryngeal  breathing  sound  to  a  vesicular.    (Penzoldt.) 

In  our  opinion,  this  explanation  is  probably  correct.  Moreover,  it 
has  this  decided  preference — that  it  forms  a  good  foundation  for  com- 
prehending almost  all  the  pathological  appearances.  Hence,  we  do 
not  mention  other  ways  of  explaining  vesicular  breathing  here,  but 
remark  that  very  excellent  authorities,  particularly  Dehio,  prefer  other 
explanations.  Thus  far,  positive  proofs  have  not  been  produced  for 
any  of  the  assumed  methods  of  producing  vesicular  breathing. 

Sometimes  there  are  special  peculiarities  of  vesicular  hreathing 
sound  quite  tvithin  the  normal,  which  may  easily  mislead  the  beginner. 
We  may  see  during  inspiration  interrupted  or  jerking  respiration  in 
persons  who,  at  discretion,  take  deep  breaths  imperfectly,  in  a  jerking 
manner ;  and,  further,  in  whining  children,  who  half  suppress  their 
sobs.  This  kind  of  jerking  breathing  exists  over  all  portions  of  the 
lungs  alike.  Moreover,  in  the  portion  surrounding  the  heart,  and  as 
far  up  as  to  the  apex  of  the  left  lung,  the  vesicular  murmur  exhibits 
interruptions  exactly  corresponding  to  the  action  of  the  heart  (systolic 
vesicular  breathing,  depending  upon  the  unequal  entrance  of  air  into 
this  portion  of  the  lung  in  consequence  of  the  changed  condition  of 
the  heart,  and,  hence,  often  especially  plain  in  disturbed  heart's 
action). 

To  learn  to  distinguish  between  the  bronchial  and  vesicular 
breathing  is,  for  the  beginner,  among  the  most  difficult  things  in 
diagnosis.  For  the  comprehension  of  the  latter  sound  it  is  strongly 
recommended  always  to  auscult  directly,  since  the  sound  is  then 
louder  and  its  nature  can  thus  be  more  clearly  recognized.  More 
than  this,  it  is  well  to  place  the  ear  frequently,  for  comparison,  upon 
the  patient's  neck,  so  as  there  to  hear  the  bronchial  sound. 


144  SPECIAL  DIAGNOSIS. 

4.  Pathological  Sounds  in  the  Respiratory  Apparatus. 

The  following  are  enumerated  : 

{a)  Certain  changes  in  the  vesicular  breathing. 

(h)  Broi/bhial  breathing,  in  place  of  vesicular  breathing. 

(c)  The     so-called    indefinite,  transition,   breathing  [broncho- 
vesicular]  . 

(d)  Dry  rales. 

(e)  Moist  rales. 
(/)  Crepitant  rales. 

{g)  Friction-sound  of  the  pleura, 
(/i)  Succussion-sound  of  Hippocrates. 

From  this  enumeration,  and  still  more  from  what  follows,  it  is 
evident  that  the  number  of  pathological  sounds  to  be  heard  with  the 
diseases  of  the  respiratory  apparatus  is  not  small.  The  chief  difficulty 
is  that  very  often  different  ones  are  to  be  heard  at  the  same  time,  so 
that  one  sound  conceals  another.  It  is  urgently  recommended  that 
the  beginner  at  first  practise  in  such  a  way  that,  in  auscultating,  he 
endeavor  always  in  the  first  place  to  learn  to  recognize  only  the 
breathing  sound,  and  that  he  then  endeavor  to  direct  his  attention  to 
other  possible  so-called  accessory  sounds  (rales,  friction-sounds).  One 
can  acquire  the  power  to  exclude  one  sound  in  order  to  be  able  more 
exactly  to  pay  attention  to  another — to  acquire  a  certain  dexterity 
which  very  much  facilitates  auscultation. 

{a)  Alterations  of  Vesicular  Breathing. — 1.  The  vesicular 
breathing  sound  may  be  increased  in  inspiration,  or  sharpened.  This 
takes  place  whenever  the  respiration  is  increased,  as  in  active  deep 
breathing :  in  the  acme  of  Cheyne-Stokes  breathing ;  in  certain  forms 
of  dyspnoea,  as  of  diabetic  coma ;  and  Avhere  one  section  of  lung  is 
vicariously  nerforming;  the  work  of  others  which  have  been  shut  off. 

Moreover,  it  forms  a  very  important  sign  in  bronchitis,  here  occa- 
sioned by  the  local  narrowing  of  small  bi'onchial  tubes  in  consequence 
of  swelling  of  the  mucous  membrane  and  accumulation  of  mucus.  Not 
infrequently  beginning  tuberculosis  of  the  apex  is  revealed  solely  by 
sharpened  vesicular  breathing  in  comparison  with  the  sound  side,  as 
evidence  of  accompanying  catarrh  of  small  bronchial  tubes. 

Here  the  one-sidedness  of  the  sharpened  vesicular  breathing  is  of 
the  greatest  importance ;  two-sided  sharpened  breathing  of  the  upper 
portion  of  both  lungs  almost  never  has  this  signification ;  not  infre- 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.        I45 

quentlj  it  exists  in  tightly-laced  women,  also  in  children  who  breathe 
poorly  with  the  lower  portions  of  the  lungs  in  consequence  of  a  high 
position  of  the  diaphragm,  due  to  abdominal  affections. 

2.  Vesicular  breathing  may  be  diminished,  either  in  67"owcA/aZca<arrA 
in  case  the  entrance  of  air  into  a  section  of  lung  is  notably  diminished 
by  the  swelling  and  secretion ;  or  if  bronchial  branches  are  more  or 
less  closed  by  foreign  bodies  or  compression.  Diminished  breathing 
of  a  portion  of  lung  is  also  a  consequence  oi pleural  thickening,  and 
of  many  conditions  which  give  pain  in  respiration,  manifested  by  the 
lessened,  weakened  breathing  of  the  affected  side.  Diminished  inter- 
change of  air  everywhere,  and,  hence,  a  two-sided  extensive  weakened 
breathing  exists  in  emphysema,  also  in  stenosis  of  the  upper  air- 
passages.  All  thickenings  of  the  chest-wall  (tumors,  etc.,  oedema) 
weaken  the  respiratory  sound  by  rendering  the  conduction  more  diffi- 
cult ;  and,  finally,  marked  weakening  develops  rapidly  with  pleural 
exudations,  both  on  account  of  the  diminished  breathing  and  the  more 
difficult  propagation  of  the  breathing  sound  by  the  layer  of  fluid. 

In  all  these  cases  the  breathing  sound  may  even  completely  dis- 
appear ;  most  frequently  is  this  the  case  with  pleural  exudations,  also 
in  complete  closing  of  a  large  bronchial  hranch,  but  it  may  exist  even 
in  emphysema. 

3.  Prolonged  expiration.  This  occurs  when  the  exit  of  the  air  from 
the  alveoli  is  more  prolonged  than  is  normal,  and  this  condition  may 
be  dependent  upon  diminished  elasticity  of  the  lung-tissue :  emphysema 
or  bronchitis — a  certain  degree  of  bronchial  narrowing,  which  does 
not  hinder  the  entrance  of  air,  but  its  exit  only.  Of  these  two  con- 
ditions, prolonged  expiration  is  an  important  diagnostic  mark,  and 
here,  again,  especially  comes  into  consideration  bronchitis  which  ac- 
companies the  commencement  of  tuberculosis  of  an  apex  of  the  lung. 
The  prolonged  expiration  of  bronchitis  is  also  generally  sharpened, 
more  markedly  aspirant,  somewhat  more  distinctly  bronchial  than 
normal.  With  pronounced  bronchial  expiration  thickening  may  be 
conjectured  to  have  taken  place.     (See  below.) 

4.  Jerking  inspiration  may  likewise  be  a  sign  of  bronchitis,  namely, 
in  case  the  two  conditions  are  excluded  which,  within  the  normal, 
cause  these  or  a  like  phenomenon  (see  above.  Sec.  3,  p.  148).  This 
pathological  jerking  respiration,  according  to  its  prominence,  is  con- 
fined to  the  region  of  the  bronchitis,  generally  to  an  apex,  as  in 

10 


146  SPECIAL  DIAGNOSIS. 

phthisis,  and  thus  is  distinguished  from  the  interrupted  inspiration  of 
awkward  breathing ;  but  it  exists  always  at  the  beginning  of  the 
examination.  It  results  from  the  delayed  entrance  of  the  air  into  the 
lung  portion  of  the  bronchial  tubes,  if  these  are  narrowed  by  catarrh. 

It  takes  place  with  sharpened  and  with  jerking  breathing,  and 
hreathing  with  prolonged  expiration,  since  in  the  majority  of  cases  it 
is  called  forth  or  is  accompanied  by  bronchitis,  generally,  also,  tone- 
less rSles.     (See  below.) 

{h)  Bronchial  Breathing. — In  order  to  understand  the  patho- 
logical development  of  this  respiratory  sound,  it  first  is  of  the  greatest 
importance  that  it  should  be  made  clear  how  the  respiratory  sound 
normally  at  the  glottis,  pathologically  also  at  every  sudden  narrowing 
of  a  not  too  small  bronchus,  exists  as  a  bronchial  sound,  how  it  is 
further  conveyed  by  the  subdivided  columns  of  air  in  the  bronchial 
tree  as  a  bronchial  sound,  and  how  in  healthy  persons  it  is  deadened 
by  lung-tissue  normally  containing  air  into  the  vesicular  breathing 
sound.  There  is  no  breathing  sound  without  open  bronchial  tubes  ; 
there  is  no  vesicular  breathing  without  lung-tissue  containing  air.  If 
between  the  bronchi  and  the  ear  there  is  no  air-containing  lung-tissue, 
if  anything  at  all  is  heard,  it  is  bronchial  breathing. 

Pathologically,  bronchial  breathing  occurs  in  thickening  of  lung- 
tissue  of  a  certain  extent — that  is,  in  case  it  involves  an  extent  that 
reaches  as  far  as  moderately  sized  bronchial  tubes.  Here  belong  acute 
and  chronic  'pneumonia,  infarction,  under  some  circumstances  new 
formations;  and,  also,  compression  of  the  lungs  so  that  the  air  is 
expelled  by  a  correspondingly  large  pleuritic  exudation  (this  is 
generally  near  the  upper  posterior  boundaries),  or  by  tumors  of  any 
kind  in  the  chest-cavity,  or  by  very  high  position  of  the  diaphragm. 

If  these  conditions,  which  encroach  upon  the  space  of  the  chest, 
only  involve  retraction  of  the  lungs  so  that  they  still  contain  air,  the 
breathing  remains  vesicular ;  on  the  other  hand,  if  they  are  so  strong 
that  they  also  compress  the  larger  bronchial  tubes,  then  we  do  not 
hear  anything  at  all. 

If  a  pneumonia  is  combined  with  a  stopping  of  the  bronchial  tubes 
(mucus,  fibrin),  then,  on  account  of  this  imperviousness,  we  do  not 
hear  anything,  but  after  a  cough  the  bronchial  tubes  may  become 
pervious :  there  is  bronchial  breathing. 

Moreover,  we  hear  bronchial  breathing  over  the  lung-cavities  and 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.       l^J 

in  open  pneumothorax  ;  and  besides,  over  the  former,  sometimes  over 
the  latter,  we  always  hear  it  in  the  form  of  amphoric  breathing  (see 
below).  It  is  only  when  the  cavity  is  near  the  surface  that  we  have 
bronchial  breathing  over  it,  when  it  is  surrounded  by  tissue  that 
contains  no  air  and  is  in  open  communication  with  a  not  too  small 
bronchial  branch.  In  both  conditions  the  bronchial  sound  really 
arises  from  the  fact  that  the  air,  flowing  out  of  the  bronchus  that  con- 
nects with  the  cavity,  or  which,  connected  with  a  pleural  cavity,  enters 
into  a  larger  air-space,  or  out  of  this  air-space,  again,  into  a  narrow 
bronchial  canal,  is  set  into  whirling  motion.  But  there  is  no  doubt 
that,  besides,  the  sound  that  is  conveyed  from  the  glottis  joins  with  it 
as  bronchial.  (See  further  upon  this  point  under  Amphoric 
Breathing.) 

In  the  cases  just  mentioned,  the  bronchial  breathing  sound  may, 
under  various  circumsta::'',es,  become  weakened,  namely,  either  when 
the  advance  of  the  sound  to  the  ear  is  made  difficult,  or  when  the 
breathing  is  weakened.  Thus,  of  an  exudative  pleuritis,  in  conse- 
quence of  the  fluid  which  generally  lies  between  the  ear  and  the 
compressed  lung,  a  slight,  distant-sounding  bronchial  breathing  is 
characteristic  ("breathing  of  compression");  Avhile,  on  the  other 
hand,  in  croupous  pneumonia,  almost  always  there  exists  a  very  loud, 
sharp  bronchial  sound.  E^t  in  pneumonia  otherwise  rare  conditions 
in  their  turn  may  weaken  the  bronchial  breathing ;  in  closure  of  the 
bronchial  tubes,  as  was  mentioned  before,  we  hear  low  bronchial 
breathing,  or  else  nothmg  at  all;  further,  in  the  so-called  central 
pneumonia  it  may  happen  that  from  the  part  of  the  lung  containing 
air  which  lies  superficially,  a  vesicular,  and,  almost  concealed  by  this, 
a  low  bronchial  breathing  sound  is  produced.  Also,  the  loud  pneu- 
monic bronchial  breathing  may  be  weakened  if  the  pneumonia  is  com- 
plicated with  an  exudative  pleurisy. 

In  all  these  cases  the  low  bronchial  sound  is  usually  most  distinct 
during  expiration  (compare  what  was  said  above  regarding  expiration), 
often  even  only  perceptible  in  expiration  as  a  weak  "ch"  kind  of 
blowing. 

The  bronchial  breathing  of  a  hollow  space  may  be  weakened,  or 
even  lost — weakened,  in  temporary  narrowing  or  closing  of  the 
bronchus  leading  to  it,  by  mucus  (hence,  loosened  by  cough) ;  or  lost, 
by  the  filling  of  the  cavity  with  secretion.    On  the  other  hand,  a  thick 


148  SPECIAL  DIAGNOSIS. 

callous  pleura  covering  a  cavity  may  be  the  occasion  of  deadness  before 
bronchial  breathing  is  affected. 

Special  forms  of  bronchial  breathing  are  the  amphoric  and  the 
metamo7'pho8ing  breathing.  The  former  exists  with  very  large, 
smooth-walled,  communicating  cavities  and  in  open  pneumothorax. 
It  is  a  bronchial  sound  with  metallic  tone,  exactly  analogous  to  the 
metallic  percussion  sound  that  arises  by  resonance  in  large  smooth- 
walled  cavities. 

It  may,  moreover,  be  found  besides  in  open  pneumothorax  (and 
where  there  is  valvular  connection),  also  in  closed^  although  more, 
rarely  and  only  very  softly,  since  here  the  (bronchial)  sound  of  the 
air  flowing  into  the  trachea  acquires  a  resonance  in  the  air-containing 
pleural  cavity;  likewise,  rales,  heart-sounds  may  acquire  a  metallic 
tone. 

Metallic  associated  sound  may  also,  in  rare  cases,  accompany  un- 
defined— that  is,  bronchial  breathing  unnoticeably  weakened;  thus 
also,  not  rarely,  in  pneumothorax.  It  might,  indeed,  be  suitable 
to  designate  it  not  as  "amphoric,"  but  as  "undefined,  with  metallic 
associated  sound." 

Metamorphosing  breathing  (Seitz).  In  this  the  inspiration  is 
divided  :  it  begins  distinctly  bronchial,  like  the  sound  of  stenosis,  and 
suddenly  changes  to  a  weak  bronchial  breathing,  which  is  then  also 
heard  during  expiration.  This  phenomenon  is  very  rare;  it  is  said 
to  be  a  sure  sign  of  cavity.  It  is  explained  that  the  bronchus  leading 
to  the  cavity  is  always  first  narrowed,  and  in  the  second  part  of 
inspiration  it  becomes  dilated  by  the  current  of  air  (?). 

(c)  Undefined  Breathing. — The  breathing  sound  may  in  two 
ways  be  of  such  a  character  that  it  may  be  designated  either  as  dis- 
tinctly vesicular  or  as  distinctly  bronchial.  It  may  be  so  weak  that 
its  character  remains  indistinct,  or  it  is  concealed  or  drowned  by  other 
sounds,  particularly  by  rales ;  or,  while  it  can  be  heard,  it  does  not 
entirely  correspond  to  either  type  of  breathing,  but  seems  rather  to 
stand  between  the  two,  thus  sometimes  inclining  more  to  bronchial, 
at  other  times  more  to  vesicular,  breathing — "  transition  breathing," 
"hinted  or  indistinct  bronchial  or  vesicular  breathing,"  "sharp 
breathing  with  bronchial  breath  in  expiration,"  etc. 

The  causes  of  what  is  included  in  the  first  category  are  very  various 
(see  what  was  said  above  concerning  the  strength  and  weakness  of  the 


EXAMINA  TION  OF  THE  RESPIRA  TOR Y  A PPARA  TVS.        1 49 

breathing  sound).  Of  course,  the  examiner's  sharpness  of  hearing  is 
an  important  factor  here.  Rales  that  may  be  present  may  frequently 
be  removed  or  diminished  by  coughing  strongly. 

The  second  group  of  undefined  breathing  is,  of  course,  much  more 
numerous  with  beginners  than  with  those  who  are  practised  in 
auscultation.  It  is  well,  however,  for  the  latter  also  to  impose  upon 
themselves  some  reserve  in  pronouncing  whether  it  is  vesicular  or 
bronchial.  The  determination  is  often  actually  possible  either  by 
the  tone  itself  or  by  the  strength  of  expiration  in  relation  to  inspira- 
tion. Frequently,  also,  as  in  beginning  phthisis,  in  various  lobular 
pneumonic  deposits,  the  physical  conditions  resulting  from  the 
pathologico-anatomical  changes  cause  it  to  appear  that  there  is  a 
*' transition  breath  " — that  is,  a  mingling — in  that  the  infiltrated  part 
of  the  lung  favors  the  transmission  of  the  bronchial  sound  unchanged, 
the  parts  containing  air  convey  the  breath-sound  to  the  ear  toned 
down  to  the  vesicular  sound.  Hence,  under  no  circumstances  can  we 
miss  this  idea  of  "transition  breathing,"  and  it  is  best  in  such  cases 
simply  to  describe  the  breath-sound. 

id)  Dry  Rales  (Rhonchus,  Humming,  Whistling,  Hissing). — 
Like  all  rales,  these  are  pathological  sounds ;  they  appear  when  there 
is  a  bronchial  catarrh,  which  furnishes  a  tough,  scanty  secretion ;  they 
constitute  those  audible  phenomena  that  are  caused  by  the  rushing 
together  of  the  air  and  secretion  in  the  bronchial  tubes.  It  is  as 
difficult  to  make  a  sharp  distinction  between  a  "  tough  "  and  a  "fluid" 
secretion  of  the  bronchial  tubes  as  in  a  stricter  sense  it  is  to  separate 
the  so-called  "  dry  "  from  what  is  later  referred  to  as  "moist"  rales — 
much  more,  since  transitions  are  everywhere  present.  Meanwhile, 
however,  the  class  of  sounds  here  referred  to  take  a  somewhat  special 
place,  both  on  account  of  the  auditory  impression  they  make  and  be- 
cause they  exactly  correspond  to  the  very  toughest  bronchial  secretions. 
The  humming,  hissing,  whistling  sounds  (sonorous,  sibilant  r§,les) 
arise  from  the  fact  that  the  swelling  and  mucus  narrow  the  bronchial 
air-passage,  and,  hence,  they  are  sounds  of  stenosis ;  but,  besides,  some 
of  the  very  fine  high  hissing  and  whistling  tones  may  be  caused  by 
the  presence  in  the  bronchial  lumen  of  tense  threads  of  mucus  stretched 
across,  which,  like  the  strings  of  an  ^olian  harp,  are  blown  upon  by 
the  current  of  air. 

Sibilant  rales  very  often  have  such  a  high  musical  tone  that  it 


150  SPECIAL  DIAGNOSIS. 

cannot  be  deadened  even  by  the  air-containing  lung.  Under  some 
circumstances  they  may  be  confounded  with  the  so-called  ringing  rS,les 
[metallic  rales].  The  dry  humming  often  shows  unnoticeable  transi- 
tions to  the  character  of  the  sound  of  the  moist  rales,  approaching 
more  nearly  to  crepitation.  According  to  my  view,  they  may  still 
as  dry,  become  ringing,  r^les — that  is,  may  exhibit  a  ringing  character 
like  bronchial  breathing.  This  is  the  case  when  we  have  thickening 
of  the  lungs  and  at  the  same  time  bronchitis  with  tough  mucus.  (See 
ringing  rales,  under  Moist  Rales.) 

The  humming,  hissing,  whistling  may  be  abundant  or  scanty,  loud 
or  soft.  It  may  occupy  the  whole  time  of  inspiration  and  expiration 
and  completely  conceal  the  breath-sound,  or  it  may  only  be  heard  at 
the  end  of  inspiration.  A  very  fine  soft  whistling  is  sometimes  heard 
during  the  whole  of  expiration,  since  then,  so  far  as  vesicular  breathing 
is  concerned,  the  breath- sound  is  very  soft.  When  they  are  very  loud 
they  may  even  be  heard  at  a  distance  (a  distinguishing  peculiarity  of 
emphysema).  Finally,  there  are  buzzing  sounds  in  the  chest  which 
may  be  felt  when  the  hand  is  applied  to  it.  Cough  has  sometimes  the 
efiect  of  diminishing,  and  sometimes  of  increasing,  them — at  least  the 
humming  is  generally  very  markedly  changed  by  it. 

It  is  not  easily  possible  to  confound  the  humming  sounds  with  the 
pleuritic  friction  sounds  [q.  v).  On  the  other  hand,  I  have  not  in- 
frequently found  that  a  very  soft,  fine  humming  was  mistaken  by 
beginners  for  sharp,  even  bronchial,  breathing  sound.  This,  as  well 
as  the  distinguishing  of  whistling  and  hissing  from  a  peculiar  ringing 
rale,  can  only  be  learned  by  practice. 

Conclusions.  Humming,  whistling,  hissing  sounds,  as  has  been 
shown  above,  show  a  dry  bronchial  catarrh.  Spread  over  the  lungs, 
they  are  present  with  diffuse  bronchitis,  with  tough  secretion,  when  it 
occurs  independently,  but  especially  as  an  accompaniment  o^ emphysema, 
in  which  they  are  almost  never  wholly  wanting.  In  these  cases  the 
lower  lobes  of  the  lungs  are  generally  the  seat  of  the  catarrh.  When 
there  is  simply  bronchitis,  then  these  r§,les  and  a  sharpened  or 
weakened  breathing  are  the  only  local  physical  signs  of  disease.  In 
emphysema  the  percussion  and  auscultatory  signs  of  this  condition 
are  also  present.  Localized  dry  rales  exist  as  signs  of  catarrh  of  the 
apices,  which  accompanies  commencing  tuberculosis;  here  a  low 
whistling  in  a  perhaps  somewhat  prolonged  expiration  may  for  a  long 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.       151 

time  form  the  only  symptom.  Ringing  dry  r^les  are  rare;  I  have 
most  frequently  heard  them  in  pneumonia  at  the  beginning  of  the 
second  stage. 

In  all  these  cases  the  dry  rales  may  be  combined  with  the  moist; 
regarding  these  see  beloAv. 

{e)  Moist  Rales. — These  arise  in  the  bronchial  tubes,  except  the 
smallest,  and  in  the  pathological  cavities  of  the  lungs  [vomicae]. 
Their  production  requires  more  or  less  fluid  secretion ;  the  more  fluid 
there  is  the  more  moist  the  sound;  if  it  is  tougher,  then  there  are 
"viscid-moist"  rales,  a  transition  to  the  dry.  Generally,  the  ear 
directly  receives  an  impression  of  a  greater  or  less  degree  of  moisture. 

Formerly,  moist  rales  were  explained  as  being  produced  by  the 
bursting  of  bubbles  which  the  current  of  air  caused  upon  the  surface 
of  the  fluid.  More  recently,  they  have  received  another  explanation  : 
according  to  the  analogy  of  the  bubbles  which  we  see  formed  when 
we  blow  through  a  tube  one  end  of  which  is  immersed  in  water,  it  is 
supposed  that  the  current  of  air  separately  moves  the  air-bubbles 
which  present  projections  into  the  bronchial  tubes,  and  that  as  one 
such  quantity  of  air  breaks  the  bridge  through  the  fluid  and  advances, 
the  fluid  behind  it,  immediately  rushing  on  again  and  occupying  the 
space,  shares  the  vibration  in  the  pent-up  air  (Talma,  Baas).  It  is 
to  be  added  that  many  consider  moist  r^les  in  part  due  to  stenosis ; 
and,  finally,  that  it  is  said  that  the  to-and-fro  motion  of  the  secretion 
produced  by  the  current  of  air  causes  r^les  (Traube).  The  explana- 
tion by  Talma  and  Baas  will  serve  very  well  for  the  rales  formed  in  the 
medium-sized  bronchial  tubes  ;  for  vomicae  it  only  serves  in  case  the 
bronchial  tubes  leading  thereto  are  immersed  in  the  fluid  secretion, 
which,  indeed,  is  ordinarily  not  the  case.  Here,  and  with  large 
bronchial  tubes  at  any  rate,  we  must  think  of  bursting  bubbles. 

Moist  rales  may  be  so  numerous  that  they  can  be  heard  in  both 
inspiration  and  expiration,  even  outlasting  the  expiration.  If  they 
are  scanty,  then  we  are  apt  to  hear  them  during  inspiration,  under 
some  circumstances  only  toward  the  close  of  inspiration.  A  slight 
cough  may  increase  them,  or  cause  them,  in  case  they  were  for  the 
time  being  absent. 

In  cases  where  the  r^les  are  very  scanty,  scarcely  to  be  heard,  it  is 
useful  to  inquire  as  to  the  time  of  day  the  cough  is  the  most  frequent, 
and  to  listen  to  them  before  the  occurrence  of  the  paroxysm  of  cough, 


152  SPECIAL  DIAGNOSIS. 

SO  as  to  make  the  examination  before  the  bronchial  tubes  have  been 
cleared  of  mucus  (as  shortly  after  waking). 

The  diiferent  moist  r§,les  make  an  impression  upon  the  ear  of  dif- 
ferent ''size,"  and  even  beginners  can  without  difficulty  judge  approxi- 
mately whether  they  are  found  in  a  large  or  a  small  bronchus  or  cavity ; 
we  speak  of  large,  small,  also  medium-sized  rales.  The  discrimination 
of  rales  in  this  respect  is  very  important ;  for  instance,  we  may  distin- 
guish whether  we  have  a  bronchitis  of  only  the  large,  or  whether  the 
smaller  tubes  have  become  involved ;  the  dangerous  capillary  bronchitis 
of  childhood  is  manifested  by  very  small,  fine  rales,  and  also  by  crepi- 
tant r^les  (see  below,  page  154).  Large  rales  may  furnish  an  index 
in  the  examination  of  the  apices :  these  contain  only  very  small 
bronchi ;  hence,  if  in  an  apex  there  are  large  or  only  medium-sized 
rS,les,  these  cannot  arise  from  the  bronchi  there,  hence  there  must  be 
a  pathological  space — a  cavity.  If  there  are  large  rale  sounds  which 
undoubtedly  arise  in  the  apex,  they  are  a  most  certain  sign  of  cavity. 

The  loudness  of  the  rales  does  not  depend  upon  their  number,  but 
upon  the  strength  of  the  breathing.  But  the  loudness  furnishes  an 
indication  of  the  place  where  they  arise :  coeteris  paribus,  the  sound 
will  be  loudest  at  the  point  where  the  ear  is  nearest  to  them.  It  may 
be  of  the  very  greatest  importance  to  locate  them  exactly.  Here, 
again,  the  most  striking  example  concerns  the  diagnosis  of  phthisis, 
and,  too,  of  the  ominous  catarrh  of  the  apex.  By  a  superficial  exami- 
nation it  may  easily  happen  to  the  inexperienced,  especially  in  the 
examination  of  the  back,  that  he  locates  r^les  which  come  from  the 
neighborhood  of  the  root  of  the  lungs  and  are  those  of  a  benign 
bronchitis  in  the  apex,  and  hence  makes  the  diagnosis  of  phthisis. 

It  is  of  the  very  highest  value,  but  often  not  easy,  to  distinguish 
whether  we  have  a  ringing  or  "consonant "  (Skoda),  or  a  non-ringing 
rale-sound.  The  former  is  acoustically  related  to  the  latter,  as  the 
bronchial  breathing  sound  is  to  the  vesicular  (as  tympanitic  percussion 
note  to  lung-sound),  and,  like  that,  ringing  r^les  appear  if  there  be 
present  either  a  thickening  of  the  lung  of  sufficient  extent,  or  if  there 
be  a  cavity.  But  yet  bronchial  breathing  and  ringing  rSles,  and 
vesicular  breathing  and  non-ringing  r§,les,  are  not  always  necessarily 
associated  together ;  thus,  not  infrequently  when  there  are  small 
cavities,  and  even  large  ones,  especially  in  the  lower  lobes,  in  case 
they  are  covered  by  a  not  very  thick  layer  of  air-containing  tissue,  we 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.        153 

hear  ringing  rales  when  the  breathing  is  undefined,  yet  hinting  toward 
the  vesicular.  In  children,  even  when  there  is  no  trace  of  cavity  or 
thickening,  in  simple  bronchitis  the  r^les  may  reach  the  ear  as  loudly 
ringing  (from  the  elasticity  of  the  lungs  and  of  the  thorax).  On  the 
other  hand,  in  pneumonia  and  pleurisy  we  sometimes  hear  bronchial 
breathing  and  non-ringing  r^les. 

But  now,  corresponding  to  "transition  breathing,''  very  frequently 
there  are  to  be  heard  such  rales  as  stand  between  the  non-ringino;  and 
the  pronounced  ringing  ("'hinted"  or  slightly  ringing  rales).  It  is 
often  difficult  to  interpret  these.  In  general,  with  children  they  fur- 
nish no  reason  for  the  supposition  of  thickening  or  cavity  more  than 
with  adults. 

Loud  ringing,  hinted  ringing,  and  non-ringing  rales  are  often  found 
together ;  we  may  even  say  that  almost  never  do  we  hear  ringing  rS.le8 
alone  at  one  place.  But,  of  course,  if  they  are  present  they  predominate. 
Though  they  exist  very  near  together,  yet  they  can  be  locally  separated, 
as  sometimes  in  emphysema  ;  here,  with  extensive  humming,  whistling, 
and  non-ringing  rS,les  at  a  certain  point  of  the  lower  lobe,  there  may 
be  ringing  rS,les  (perhaps  without  bronchial  breathing,  and  without 
deadened  or  tympanitic  resonance)  :  this  makes  a  bronchiectatic 
cavity  probable.  But,  also,  by  the  same  signs,  in  general  bronchitis 
a  broncho-pneumonic  deposit  may  be  made  known. 

As  the  ringing  r^les  correspond  to  bronchial  breathing,  so  in  their 
manifestation  the  so-called  metallic  r^les  correspond  to  amphorie 
hreathing  (metallic  percussion  note) ;  but  again  in  such  a  way  that 
the  two  symptoms  are  not  necessarily  united  together.  The  metallic 
rSles  then  occur  in  correspondence  with  very  large,  smooth-walled, 
superficially-located  cavities,  and  also  in  pneumothorax,  where,  arising 
from  sections  of  the  lungs  which  are  breathing  (even  if  on  the  other 
side),  they  are  to  be  regarded  as  rS.le-sounds  in  the  air-containing 
pleural  cavities  endowed  with  resonance. 

Sounds  of  falling  drops.  These  are  often  only  separate,  generally 
very  much  inflated,  moist  rEles,  which  have  a  high  metallic  note; 
sometimes,  indeed,  there  is  only  one  in  each  phase  of  the  breathing; 
then  the  above-mentioned  designation  of  it  serves. 

Water-whistling^  or  the  sound  of  lung-fistula  (Unverricht,  Riegel). 
We  thus  designate  a  metallic  rale,  or  very  fine  metallic  gurgling  or 
splashing,  which  occurs  in  open  pneumothorax,  if  the  patient's  position 


154  SPECIAL  DIAGNOSIS. 

is  such  that  the  opening  in  the  pleura  is  directly  below  the  smooth 
surface  of  the  fluid,  and  if  the  patient  then  draws  a  breath  (first 
observed  by  Unverricht  while  puncturing  and  aspirating  a  case  of 
hydro-'pneumothorax. 

(/)  Crepitant  Rales  (Crepitation). — Briefly  expressed,  by  this 
we  understand  the  finest  r§,le  sounds.  It  occupies  a  special  place  on 
account  of  its  acoustic  peculiarity,  on  account  of  its  cause,  which 
permits  its  classification  either  under  the  moist  or  under  the  dry  rS.les, 
and,  finally,  on  account  of  its  special  diagnostic  meaning. 

The  so-called  atelectatic  crepitation  occurs  in  health,  and  still  more 
in  disease,  over  parts  of  the  lung  which  have  for  a  time  been  breathing 
poorly  and  now  are  again  distended  by  a  full  breath.  Most  frequently 
is  it  observed  after  quite  long,  especially  low,  dorsal  position,  over  the 
lower  parts  of  the  lower  lobes.  It  is  purely  inspiratory,  and  disap- 
pears generally  after  the  first  deep  respirations. 

Like  this  are  crepitant  rSles  which  are  to  be  heard  in  croupous 
pneumonia  during  the  first  and  in  the  beginning  of  the  third  stage 
(crepitatio  indux  and  redux),  sometimes  in  caMrrhal  pneumonia, 
moreover  in  infarction,  in  individual  cases  (according  to  the  author's 
observation)  of  caseous  pneumonia,  and,  finally,  especially  in  oedema 
of  the  lungs. 

In  all  these  cases  we  have  to  do  with  crepitation,  heard  during 
inspiration,  or,  at  most,  only  the  beginning  also  of  expiration,  which 
occurs  in  very  fine  and  equal-sized  bubbles.  It  is  well  compared  to 
the  noise  produced  by  rubbing  a  lock  of  hair  between  the  fingers  in 
front  of  the  ear,  or  by  separating  the  thumb  and  finger  moistened  and 
pressed  together  as  they  are  held  before  the  ear  (Eichhorst).  It  arises 
in  the  smallest  bronchial  tubes,  the  alveolar  spaces,  and  in  the  alveoli 
when  these  are  collapsed  and  glued  together,  or  partly  filled  with 
secretion,  and  then  during  strong  inspiration  their  walls  are  torn 
apart  or  freed  from  secretion.^ 

•  The  non-uniform  crepitation,  so  called,  forms  the  transition  from 
these  sounds  to  the  fine  bubbling  rales.  More  than  elsewhere  it 
occurs  with  capillary  bronchitis  and  also  in  oedema  of  the  lungs.  It 
is  to  be  understood  as  a  mixture  of  peculiar  crepitations  and  small 

1  It  is  only  in  individual  cases  that  this  crepitation  is  heard  in  expiration,  and  still 
more  rarely  only  in  expiration.     (Penzoldt.) 


EXA MINA TION  OF  THE  RESPIRA TOR V  A PPA RATUS.       155 

bubbling  rales,  and  it  accordingly  is,  in  its  coarse  sounds,  to  be  heard 
also  in  expiration. 

(g)  Pleuritic  Friction-sounds. — The  respiratory  gliding  of  the 
pleura  costalis  upon  the  pleura  pulmonalis,  which  normally  is  noise- 
less, is  perceived  by  the  ear  and  can  also  be  felt  when  the  hand  is  laid 
upon  the  chest  when  there  are  inflammatory  deposits  upon  the  serous 
surfaces.  Thus,  it  is  really  the  pleuritis  sicca  that  causes  it.  Only 
in  rare  cases  of  unevenness  of  the  pleura  is  this  phenomenon  observed 
in  the  absence  of  inflammation,  as  in  acute  miliary  tuberculosis  of  the 
lungs  and  pleura;  also  in  pneumono-koniosis.  The  conditions  most 
favorable  for  the  occurrence  of  this  sound  are  where  the  respiratory 
movement  of  the  lungs  (forward  and  downward)  is  most  marked :  be- 
low and  especially  at  the  sides.  But  this  sound  may  also  exist  farther 
up,  even  almost  as  high  as  the  apex. 

Pleuritic  friction  sounds  like  regular  scraping,  or  like  a  scratching, 
creaking,  beginning  in  distinct  pauses,  which  ordinarily  is  louder  dur- 
ing inspiration  than  expiration.  Quite  in  the  same  way  as  it  comes  to 
be  heard,  it  can  be  felt:  the  "sensible  frictions"  are  best  recognized 
by  the  laying  on  of  the  flat  hand.  It  is  not  changed  by  cough,  but 
continued  deep  breathing  often  causes  it  to  disappear,  since  in  this 
way  the  unevenness,  upon  which  it  depends,  is  smoothed  out. 

When  this  friction-sound  is  very  loud  and  characteristic  it  is  easily 
recognized.  A  difiiculty  may  arise  when  it  is  very  softly  heard;  this 
often  occurs  from  the  fact  that  the  examiner  does  not  auscultate  at 
the  right  spot,  for  friction-sound  is  heard  in  only  a  circumscribed 
area,  since  it  is  poorly  transmitted.  A  further  difficulty  lies  in  dis- 
tinguishing it  from  certain  medium-sized,  tough,  moist  rales  (cracking 
r§,les)  and  from  soft  buzzing ;  here  it  is  most  important  to  take  note 
of  the  character  of  the  particular  sound,  and  the  knowledge  and  recog- 
nition of  this  can  only  be  acquired  by  practice.  We  may  make  use 
of  the  efiect  of  coughing  as  an  aid.  Sometimes  moderate  pressure 
with  the  stethoscope  increases  the  pleuritic  sounds ;  also,  palpation 
may  help  us  to  recognize  them.  REle-sounds  are  seldom,  or,  at  most, 
only  slightly,  to  be  felt. 

It  is  to  be  remembered  that  friction-  and  rSle-sounds  may  occur  at 
the  same  time.  Besides  in  pneumonia,  I  have  observed  it  most  fre- 
quently in  disseminated  tuberculosis  and  in  caseous  pneumonia  of  the 
lower  lobes. 


156  SPECIAL  DIAGNOSIS. 

Friction  occurs  with  all  kinds  of  pleuritis.  It  occurs  (seldom)  in 
acute  exudative  pleuritis  in  the  beginning  of  the  attack,  and  also,  as  a 
favorable  sign,  later  with  the  absorption  of  the  fluid  exudation.  There 
can  be  no  friction-sound  while  there  is  fluid  present,  since  it  is  only- 
heard  when  the  pleural  surfaces  are  in  contact.  In  chronic  pleuritis 
it  may  last  indefinitely  and  over  a  large  extent.  Of  the  diseases  of 
the  lungs  which  usually  are  accompanied  by  pleuritis  sicca  many  are 
first  revealed  by  the  friction- sounds  which  the  latter  causes :  thus, 
phthisis,  Siho  pt/cemic  deposits  in  the  lungs,  infarction,  bronchiectasis 
with  reactive  pneumonia,  and  pleuritis  with  emphysema. 

Regarding  pleuro-pericardial  friction-sounds  (pericarditis  externa), 
see  under  Auscultation  of  the  Heart. 

(A)  HiPPOCRATic  SuccussiON. — This  is  a  phenomenon  very  easy 
to  understand. 

In  sero-  and  pyo-pneumothorax,  after  a  strong  shaking  of  the  chest, 
as  in  any  vessel  partly  filled  with  fluid,  there  is  splashing.  This 
splashing,  through  the  resonance  associated  with  metallic  tone,  like  all 
the  audible  phenomena  of  pneumothorax,  is  heard  at  a  distance  or  by 
applying  the  ear  to  the  chest. 

This  sign  is  usually  most  distinctly  manifest  when  there  is  a  small 
efiusion  and  when  it  is  serous.  It  is  almost  pathognomonic  of  hydro- 
pneumothorax  in  that  it  only  elsewhere  occurs  in  very  isolated  cases 
of  large  cavity  with  quite  fluid  contents. 

The  direction  of  Hippocrates  was  to  shake  the  patient  by  the 
shoulders ;  but,  on  account  of  the  grave  condition  of  most  of  these 
patients,  the  greatest  care  is  necessary.  Many  quickly  learn  to  shake 
the  body  so  as  to  produce  the  sound  themselves. 

Confounding  this  with  the  splashing  from  the  stomach  or  colon  will 
be  avoided  by  local  examination  of  these  organs  and  by  repeated 
examinations. 

PALPATION    OF  VOCAL   FREMITUS   (AUSCULTATION    OF   THE    VOICE). 

Strictly  speaking,  this  method  of  examination  belongs  in  part  to 
Palpation  and  in  part  to  Auscultation ;  but  at  the  same  time  it  has  a 
place  here,  because  this  comes  next  in  the  course  of  a  thorough  exam- 
ination of  patients.  It  is,  besides,  of  sufficient  importance  in  itself 
to  be  treated  separately,  because  after  Inspection,  Palpation,  Percus- 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.        157 

sion,  and  Auscultation  have  been  completed,  not  infrequently  it  hap- 
pens that  this  casts  the  decisive  vote. 

The  vibrations  of  the  glottis  in  phonation  (speaking,  singing, 
screaming)  originate  in  the  column  of  air  in  the  trachea  and  bronchial 
tubes  rather  than  in  their  walls ;  they  traverse  the  lung-tissue,  where, 
in  case  this  is  normal,  they  become  considerably  weakened,  then  the 
wall  of  the  thorax  and  its  coverings,  and  may  be  felt  by  the  hand  laid 
upon  the  chest  as  a  whizzing :  voice  vibration,  voice  fremitus,  pectoral 
fremitus  (besides  heard  as  indistinct  humming  ;  see  below). 

The  technique  of  this  method  of  examining  is  as  follows  :  While  the 
patient  counts  aloud,  or,  still  better,  repeats  the  same  word  (one,  for 
example),  the  hand  is  laid  upon  different  parts  of  the  chest.  Gener- 
ally we  employ  the  palm  of  the  hand,  but  for  finer  examination  it  is 
preferable  to  apply  the  ball  of  the  little  finger  or  the  tips  of  the  first, 
second,  and  third  fingers.  Practice  of  the  method  last  mentioned 
enables  one  to  dispense  with  auscultation  of  the  voice.  Differences  of 
voice  vibration  are  distinguished  by  comparison  of  different  locations 
and  particularly  of  symmetrical  points.  It  is  quite  unnecessary  in 
making  this  comparison  to  apply  both  hands  at  the  same  time  to  the 
two  sides  of  the  chest ;  the  difference  is  much  more  distinctly  felt  if  we 
examine  with  the  same  hand,  first  upon  one  side  and  then  upon  the  other. 

Within  normal  limits,  vocal  fremitus  is  stronger  the  stronger  the 
voice ;  it  is  very  distinct  when  the  voice  is  rough  and  deep,  weak  if 
the  voice  is  high,  and  even  not  to  be  felt  at  all  when  the  voice  is  high 
and  thin  (light),  as  is  sometimes  the  case  in  women  and  children. 
The  separate  vibrations  are  felt  more  distinctly  the  richer  and  more 
prolonged  they  are.  The  fremitus  is  stronger  upon  the  right  side  of 
the  chest  than  the  left,  probably  because  the  right  bronchus  is  the  larger 
in  diameter.  It  is,  moreover,  very  noticeably  influenced  by  the  thick- 
ness of  the  covering  (muscles,  mamma,  subcutaneous  fat). 

There  may  be  pathological  conditions  present  upon  one  side  that 
will  not  propagate  the  vibration  of  the  voice  so  well  as  a  normal  con- 
dition would  do,  which  may  diminish  or  remove  the  vocal  fremitus ; 
on  the  other  hand,  they  may  better  propagate  it ;  strengthen  the 
vocal  fremitus. 

Weakness  or  suppression  of  vocal  fremitus  occurs  with  pleuritic 
exudation  (on  account  of  the  narrowing  of  the  bronchial  tubes  from 


158  SPECIAL  DIAGNOSIS. 

compression  and  on  account  of  the  encroachment  of  the  fluid) ;  with 
'pneumotliorax,  on  the  one  hand,  either  on  account  of  the  poor  con- 
duction through  the  bronchial  tubes  of  the  retracted  or  the  compressed 
lung,  or,  on  the  other,  because  it  is  not  conducted  through  the  air- 
cavity.  If,  however,  there  should  be  growths  on  the  pleural  surfaces, 
even  if  only  in  the  form  of  fine  fibres,  these  ordinarily  act  as  good 
conductors  of  vocal  fremitus.  Finally,  vocal  fremitus  is  weak  or  sup- 
pressed with  tumors  of  the  pleura,  and  all  thickenings  of  the  chest- 
wall  (abscess,  oedema),  and  in  closure  of  the  bronchial  tubes,  since 
these  are  the  most  important  means  of  propagating  the  oscillations 
(closure  from  mucus,  masses  of  fibrin,  foreign  bodies,  compression). 

Increase  of  vocal  fremitus  is  observed  in  pneumonia,  since  the 
solidified  lung-tissue  is  a  better  conductor  than  when  it  contains  air ; 
for  the  same  reason,  sometimes,  when  the  lung  is  compressed  against 
the  thorax-wall ;  above  pleuritic  exudation,  and  generally  posteriorly 
at  the  roots  of  the  lungs ;  and  in  cavities  with  open  bronchus  and 
small  secretion — here  partly  by  the  good  conduction  of  the  sound  and 
partly  by  consonance. 

Vocal  fremitus  is  an  extremely  valuable  means  of  distinguishing 
between  pneumonia  and  pleuritic  exudation.  Yet  it  may,  in  rare  cases, 
so  far  deceive  as  that  in  pneumonia,  if  the  bronchial  tubes  are  stopped 
by  secretion,  there  is  no  increase  of  vocal  fremitus ;  it  is  even  dim- 
inished, and,  occasionally,  with  complete  filling-up  of  the  bronchial 
tubes,  may  even  disappear  altogether.  Under  some  circumstances 
after  cough  and  expectoration,  as  after  a  cool  bath,  it  may  return.  It 
is  easy  to  see  how  various  the  result  may  be  if  pneumonia  and  pleurisy, 
or  if  a  cavity  and  thickened  pleural  walls,  are  combined. 

In  most  cases,  in  my  opinion,  auscultation  of  the  voice  may  be  dis- 
pensed with  where  one  is  thoroughly  trained  in  testing  the  vibration 
of  the  voice  by  palpation,  especially  by  using  the  tip  of  the  fingers. 
In  reality,  its  result  is  fully  analogous  to  that  of  palpation.  Normally, 
over  the  thorax,  we  hear  the  voice  of  the  person  examined  as  an 
indistinct  humming,  which  pathologically  may  be  weakened  or  lost ; 
but  it  may  be  strengthened  to  an  extraordinary  loudness  (bronchoph- 
ony), wholly  under  the  conditions  which  correspond  to  those  that 
influence  vocal  fremitus. 

We  sometimes  find  a  very  marked  bronchophony  over  those  cavities 


EXA  MINA  TION  OF  THE  RESPIRA  TOR  Y  A PPA RA  TUS.        I5 9 

where  we  hear  amphoric  breathing  and  metallic  rales.  Here,  also, 
the  bronchophony  may  acquire  a  kind  of  metallic  quality  (Laennec'3 
pectoriloquy). 

^gophony,  "bleating- voice/'  is  a  peculiar  nasal,  bleating  pec- 
toriloquy, as  we  hear  it,  with  pleuritic  exudations,  in  the  neighborhood 
of  the  upper  boundary  of  dulness. 

Auscultation  of  the  lohispered  voice  was  introduced  by  Baccelli. 
He  found  that  it  was  propagated  by  serous  exudations  of  the  pleura, 
but  not  by  purulent,  since  the  latter  dispersed  the  sound-waves.  In 
most  cases  this  method  must  be  considered  as  without  value,  since  in 
large  serous  exudations  with  marked  compression  of  the  lungs  we  as 
often  do  not  hear  the  whispered  voice.  We  may  recognize  it  in  very 
small  and  fresh  nurulent  exudations,  unconnected  with  thickeninor  of 
the  pleura. 

Palpation  and  auscultation  of  the  voice,  of  course,  cannot  be  made 
in  all  those  cases  where  the  voice  cannot  be  produced,  as  in  uncon- 
sciousness and  exhaustion,  or  when  the  patient  is  dumb  (aphonic),  or 
where,  from  caution,  we  do  not  wish  to  have  the  patient  speak  aloud, 
as  in  haemoptysis,  peritonitis,  etc.  Scherwald  has  recently  devised  a 
new  procedure,  which  can  be  recommended — plegaphonia,  or  ausculta- 
tion during  percussion  upon  the  larynx  or  trachea.  The  vibrations 
produced  in  this  way  take  the  place  of  those  of  the  vocal  cords  during 
phonation,  and  this  procedure  is  exactly  synonymous  with  auscultation 
of  the  voice. 

Mode  of  application  :  We  have  some  one  else  place  a  large  ivory  or 
hard-rubber  pleximeter  upon  the  surface  of  the  thyroid  cartilage  or 
upon  the  trachea,  and  percuss  with  a  hammer  (sometimes  the  patient 
himself  can  do  both).  The  patient  closes  his  mouth.  By  preference 
we  auscult  during  expiration.  Ausculting  on  the  thorax,  we  hear 
the  blows  :  1,  over  the  sound  lung,  very  markedly  weakened  (loudest 
over  the  apices),  as  if  it  were  vanishing,  not  tympanitic,  but  with  a 
cracked-pot  sound;  2,  over  infiltrated  lung,  very  loud,  tympanitic, 
with  Wintrich's  change  of  sound  [which  see]  ;  here,  also,  the  ear  has 
a  sensation  as  if  the  blows  were  upon  itself;  3,  over  an  exudation, 
simply  weak,  even  to  complete  absence ;  4,  over  cavities,  the  same  as 
over  tissue  empty  of  air;  over  large  open  cavities,  very  loud,  "smiting"; 
5,  over  pneumothorax,  a  metallic  sound. 


160  special  diagnosis. 

Exploratory  Puncture  of  the  Pleura. 

Mode  of  procedure :  For  this  small  operation  we  employ  either  an 
ordinary  large  hypodermic  syringe,  or,  better,  a  larger  syringe  of  the 
same  construction  with  a  slightly  larger  canula — about  seven  cm.  long. 
The  syringe  must  always  be  kept  very  clean,  and  before  using  must 
be  disinfected  most  carefully  with  carbolic  acid  or  bichloride  of  mer- 
cury. The  packing  must  be  very  tight.  The  needle  is  inserted  in  an 
intercostal  space  perpendicular  to  the  surface  with  the  piston  pushed 
in,  and  then  the  piston  is  withdrawn.  If  the  point  of  the  needle  rests 
in  fluid,  this  will  rush  into  the  syringe. 

Directly  before  making  the  exploratory  puncture  the  patient  must 
be  placed  in  exactly  the  same  position  he  is  to  occupy  during  the 
operation,  then  be  carefully  examined,  and  especially  percussed. 

In  this  way  we  may  ascertain  whether  there  is  fluid  in  that  portion 
of  the  thorax,  and  of  what  kind  it  is.  It  is  especially  applicable  in 
the  diagnosis  of  pleuritis  (more  rarely  in  hydrothorax  and  hydro- 
pneumothorax).     It  is  to  be  performed  in  the  following  cases : 

1.  When  there  is  the  slightest  doubt  whether  there  is  pleuritis  or 
not.  In  the  first  place  we  have  to  consider  the  differential  diagnosis 
between  pneumonia,  tumors  of  the  chest-cavity,  and  thicJcening  of 
the  pleura  (compare  p.  158).  In  either  of  these  three  conditions 
the  syringe  will  draw  out  nothing  at  all,  or,  at  most,  only  a  drop  of 
blood.  But  positiveness  of  conclusion  is  limited  in  two  ways :  (1) 
Sometimes  we  do  not  reach  the  fluid  with  the  syringe  if  the  pleural 
exudation  is  buried  behind  a  thick  pleural  membrane,  or  behind 
tumors  of  the  chest-wall,  because  it  does  not  penetrate  as  far  as  the 
exudation.  (2)  Even  when  the  fluid  is  within  reach,  we  often  do  not 
obtain  any  in  case  it  contains  floccules  of  flbrin,  or  it  is  a  thick  puru- 
lent fluid ;  either  of  which  will  close  the  needle.  With  these  two 
possibilities,  a  limited  value  must  always  be  assigned  to  the  negative 
result  of  exploratory  puncture. 

2.  To  determine  the  nature  of  the  fluid  in  the  pleural  cavity.  If 
the  small  quantity  of  fluid  withdrawn  is  quite  or  almost  clear,  like 
water,  if  it  contains  on  material  elements,  if  there  is  no  effusion  of 
fibrin,  and  if  on  boiling '  there  is  little  or  no  albumin,  then  the  fluid  is 

1  This  test  is  difficult  with  a  small  quantity,  but  yet  by  care  it  may  be  applied  by 
using  a  small  test-tube,  and  adding  T^ater. 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.        161 

a  transudation  ;  otherwise  it  must  be  regarded  as  an  exudation.  The 
exudation  may  be  serous,  sero-fibrinous,  sero-purulent,  purulent, 
hemorrhagic,  odorless  or  ichorous,  or  feculent.  With  purulent  ex- 
udation there  are  never  wanting,  in  the  microscopic  examination, 
besides  the  pus-cells,  micrococci  (streptococci  and  diplococci) ;  of  other 
organisms  in  pleural  exudation,  the  bacillus  tuberculosis  comes  into 
consideration  (for  the  manner  of  demonstration  see  p.  188),  and  acti- 
nomyces  (see  p.  189).  The  latter  elements,  however,  can  hardly  be 
obtained  by  the  hypodermic  syringe.  Absence  of  bacillus  tuberculosis, 
even  the  negative  result  of  culture,  does  not  decide  positively  against 
tubercular  pleurisy.  Even  in  empyema  of  tuberculous  origin,  cultures 
and  inoculations  are  generally  negative.  (A.  Frankel.)  The  bacilli 
and  spores  are  only  present  in  the  exudations  if  disintegration  of 
tubercle  takes  place  upon  the  diseased  pleura.  Micrococci  are  always 
found  in  great  quantities  in  septie  pleuritis. 

In  carcinomatous  pleuritis,  carcinomatous  cells  are  sometimes  found 
in  the  exudations.  However,  Quincke,  the  greatest  authority  upon 
this  subject,  has  acknowledged  that  single  carcinomatous  cells  cannot 
with  certainty  be  distinguished  from  the  pleural  endothelium,  and  at 
best  that  this  method  of  diagnosis  is  extremely  difficult.  Both  species 
of  cells,  affected  with  fatty  degeneration  or  granular,  are  found  filled 
with  large  "vacuoles."  If  very  abundant,  both  may  form  a  cream- 
like layer  upon  the  surface  of  the  fluid  drawn  off.  We  must  think  of 
carcinomatous  cells  (which,  moreover,  can  only  occur  when  a  carcinoma 
has  ulcerated  into  the  pleura),  if  the  cells  exist  in  abundance,  are  in 
balls,  show  great  variations  in  form  and  size,  and  are  colored  brown 
by  iodine  (glycogen  reaction). 

Hemorrhagic  exudation  makes  the  existence  of  tubercle  or  car- 
cinoma of  the  pleura  probable.  If  the  exudation  \^  feculent,  there  is 
some  connection  with  the  intestine.  But,  sometimes,  there  is  no 
disease  of  the  pleura  at  all,  but  a  diaphragmatic  peritonitis  (see), 
which  simulates  a  pleuritis. 

When  pleuritis  is  complicated  with  erysipelas  we  ought  to  look  for 

the  coccus  of  that  disease.     But  this  is  very  difficult  to  distinguish 

from  other  cocci  (especially  streptococcus  pyogenes,  one  of  the  most 

important  pus-cocci),  and  it  can  only  be  distinguished  by  cultivation 

and  inoculation. 

11 


IQ2  SPECIAL  DIAGNOSIS. 

Exploratory  puncture,  finally,  must  always  be  made— 
3.  Before  operative  procedure  when  pleurisy  has  been  diagnosed, 
even  if  the  diagnosis  seems  to  be  perfectly  certain. 

In  making  the  exploratory  puncture  the  needle  and  syringe  em- 
ployed must  be  always  first  thoroughly  cleaned  and  disinfected  with 
carbolic  acid  or  corrosive  sublimate.  The  syringe  must  have  good 
suction.  From  what  has  been  said  it  is  clear  that  we  operate  only 
upon  the  lower  part  of  the  chest,  not  higher  than  the  fourth  rib  in 
front  and  the  sixth  behind.  Of  course,  we  must  avoid  the  region  of 
the  heart,  and  when  there  is  a  suspicion  of  aneurism  explorative 
puncture  must  be  omitted;  otherwise  there  is  no  need  of  anxiety. 
When  the  exploratory  puncture  is  made  with  the  observance  of  every 
possible  precaution  it  is  not  a  dangerous  procedure.  The  puncture  is 
made  quickly,  in  an  intercostal  space,  as  far  as  the  needle  will  reach  ; 
if  nothing  is  obtained,  the  needle  is  slightly  withdrawn  and  suction 
again  made.     We  may  sometimes  puncture  at  several  points. 

Methods  of  Measuring  and  Stethography. 

Measuring  the  Thorax. 

This  serves,  in  measuring  once,  to  determine  the  size  of  the  chest, 
and  to  secure  an  approximate  point  of  departure  for  determining  its 
relation  to  the  development  of  the  rest  of  the  body.  But  it  does  not 
furnish  knowledge  of  diseases  any  better  than,  with  suflScient  practice, 
is  given  by  inspection  and  palpation. 

On  the  other  hand,  it  has  a  very  great  value  in  connection  with 
tracing  the  cross-section  of  the  chest  upon  paper,  if  it  is  employed  to 
determine  the  changes  which  the  chest  undergoes  in  the  course  of  a 
certain  disease. 

We  measure  the  diameter  of  the  thorax  with  the  caliper-compasses, 
and  it  is  best  to  take  the  broad  diameter  at  the  highest  point  of  the 
axilla,  the  deep,  or  sterno-vertebral,  diameter  on  the  level  with  the 
nipple  and  the  insertion  of  the  second  rib.  In  tracing  a  cross-section 
of  the  thorax  upon  paper  we  must,  of  course,  make  the  transverse 
and  antero-posterior  diameters  at  the  same  level  (whether  at  the  nip- 
ples or  lower  down).  The  circumference  of  the  breast  is  generally 
measured  at  the  level  of  the  nipple,  but  sometimes  over  the  highest 


EXAMINA TION  OF  THE  RESPIRA TORY  A PPARA  TUS.        1 63 

.  points  of  the  axillee  and  at  the  lower  end  of  the  corpus  sterni.  The 
length  of  the  chest  may  be  ascertained  by  measuring  in  the  mammil- 
lary  line  from  the  clavicle  to  the  border  of  the  ribs.  The  linea  costo- 
articularis  is  very  useful  for  determining  any  change  in  the  length. 

The  delineation  of  the  form  of  a  cross- section  of  the  chest  is  made 
in  the  following  manner :  The  opposite  diameters  at  a  given  point  are 
measured,  and  are  marked  upon  a  sheet  of  paper.  Then  a  lead  hoop 
or  wire  is  accurately  fitted  first  to  one  and  then  the  other  side  of 
the  chest  at  that  level,  then  carefully  removed  and  traced  upon  the 
paper.  Instead  of  the  leaden  hoop  (which  is  entirely  satisfactory)  we 
may  employ  Woillez's  Cyrtometer,  which  is  a  chain  with  links  that 
move  stifily. 

Frequent  measurements  of  the  diameters  and  circumferences,  as 
well  as  tracing  the  cross-section  in  the  course  of  disease  may  give  not 
unimportant  results :  in  determining  an  increase  or  diminution  of  the 
quantity  of  pleural  exudation  or  of  the  progress  toward  recovery  by 
the  amount  of  shrinking ;  in  retraction  of  the  lungs ;  but  especially 
in  all  kinds  of  tumors  of  the  chest-cavity.  Thus,  where  aneurism  is 
suspected,  or  a  mediastinal  tumor,  the  slightest  increase  in  the  antero- 
posterior diameter  or  of  the  circumference  of  the  chest  is  of  great 
significance- 

In  view  of  what  has  been  said,  the  statement  of  the  exact  measure 
is  impossible.  It  is  only  important  to  know  that  the  right  side  of  the 
chest  measures,  in  people  who  are  right-handed,  about  1  to  IJ  cm. 
more  than  the  left ;  also,  that  the  circumference  of  the  chest  at  the 
level  of  the  nipples  in  healthy  persons  is  increased  in  inspiration  about 
5  to  7  cm. 

Spirometry,  Pneumatometry,  and  Stethography. 

If  we  here  discuss  these  three  methods  of  examination  somewhat 
briefly  and  dogmatically,  let  it  be  understood  that  this  is  only  from 
the  point  of  view  of  clinical  diagnosis.  But  as  to  the  application  of 
these  methods  to  physiological  and  pathological  examinations  in  ani- 
mals and  man  we  take  exactly  the  opposite  view,  for  they,  like  meas- 
urements of  the  chest,  can  furnish  many  important  conclusions. 

Spirometry  is  employed  to  ascertain  the  vital  capacity  of  the  lungs 
— that  is,  the  quantity  of  air  which,  after  deepest  inspiration,  can  be 


164  SPECIAL  DIAGNOSIS. 

given  off  by  the  deepest  expiration.  This  is  done  by  means  of  a 
Hutchinson's  spirometer,  which  is  constructed  on  the  principle  of  a 
gasometer. 

The  relations  of  the  size  of  the  body  to  the  vital  capacity  of  the 
lungs  are  relatively  the  most  constant.  Von  Ziemssen  found  that  in 
men,  if  to  each  cm.  of  stature  there  was  less  than  20  c.cm.  of  vital 
capacity  (or,  in  the  case  of  women,  less  than  17  c.cm.),  there  probably 
was  a  considerable  disturbance  in  the  organs  of  respiration  (phthisis, 
emphysema,  adhesive  pleuritis,  bronchitis),  or  it  already  definitely 
existed.  On  the  other  hand,  where  the  relation  was  as  1  :  25  (or 
1  :  22)  this  was  improbable.  The  vital  capacity  is  of  more  importance 
for  supplementing  other  methods  of  examination  in  the  course  of 
observation  of  a  patient,  for  the  reason  that  it  changes  with  the 
recovery  from,  or  exacerbation  of,  the  given  disease.  It  is  to  be 
observed  that  there  seems  to  be  an  increase  in  the  vital  capacity  of 
every  patient  in  consequence  of  increased  practice.  Spirometry  does 
not  here  have  an  independent  value. 

Pneumatometry  is  the  determination  of  the  pressure  of  the  respira- 
tory air  during  inspiration  and  expiration.  It  is  determined  by  means 
of  the  pneumatometer  of  Waldenburg,  improved  by  Biedert  and  Eich- 
horst,  a  modified  mercurial  manometer.  We  find  that  in  health  the 
expiratory  pressure  is  always  greater  than  the  inspiratory,  but  the 
absolute  results  vary  still  more  than  those  obtained  by  spirometry. 
The  diminution  of  the  expiratory  pressure  in  emphysema  is  important, 
and  furnishes  a  certain  conclusion  as  to  the  severity  of  the  disease,  as 
well  as  of  improvement  or  extension.  Diminished  inspiratory  pres- 
sure in  stenosis  of  the  air-passages,  in  phthisis,  and  in  exudative 
pleuritis  has  no  diagnostic  meaning. 

Stethography  is  the  graphic  delineation  of  the  respiratory  motions 
of  the  chest  and  of  the  diaphragm.  In  many  ways  it  is  instructive 
and  yields  results  that  are  valuable  with  reference  to  physiology  and 
pathology,  but  it  may  be  entirely  dispensed  with  for  the  purposes  of 
clinical  diagnosis. 

Cough  and  Expectoration. 

Cough  is  caused  in  the  following  way  :  By  the  closure  of  the  glottis, 
after  a  deep  inspiration  has  been  taken,  the  pressure  in  the  thorax 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.       165 

by  means  of  the  auxiliary  muscles  of  expiration  is  increased,  and  then 
suddenly  the  glottis  is  opened  ;  there  results  an  audible  outrush  of  air, 
which  in  tui^n  brings  with  it  the  substances  forming  the  expectoration 
(which  substances  cause  rales). 

The  ability  to  cough  is  lost,  not  only  when  the  crico-arytenoideus 
muscle  in  the  larynx,  but  also  the  respiratory  muscles,  are  paralyzed 
(bulbar  paralysis).     Pain,  also,  may  cause  suppression  of  cough. 

Cough  may  be  spontaneous  or  reflex.  Reflexive  cough-irritation 
may  arise  from  all  parts  of  the  mucous  membrane  of  the  larynx, 
trachea,  and  bronchial  tubes,  as  well  as  from  inflamed  pleura  ("  pleural 
cough  "),  no  doubt  occurring  not  infrequently.  The  trachea  is  espe- 
cially irritable,  and  particularly  the  region  of  the  inter-arytenoidean 
space,  likewise  the  bifurcation ;  inflamed  mucous  membrane  is  more 
irritable  than  normal.  There  is  never  any  irritative  cough  from  the 
lung-tissue. 

Cough  may  also  arise  from  the  abdominal  organs  reflexively,  as 
from  the  stomach.  I  have  known  three  persons  who  had  a  "nervous  " 
cough  at  the  beginning  of  each  menstrual  epoch.  The  cough  of 
hysteria  must  be  regarded  as  reflex,  or  direct  from  the  nervous 
centres  (?). 

The  cough  which  is  caused  by  disease  of  the  respiratory  organs  at 
the  points  above  mentioned,  either  because  these  are  themselves  dis- 
eased or  because  they  are  irritated  by  diseased  products,  is  a  most 
important  sign  of  disease.  Moreover,  in  spite  of  the  existence  of 
irritation,  there  may  be  no  cough  in  any  patient  whose  mind  is 
markedly  obtunded  (as,  for  example,  in  typhus  abdominalis  [typhoid 
fever],  in  disease  of  the  brain,  in  carbonic-acid  poisoning,  in  the 
death  agony,  etc.) ;  hence,  in  these  cases  there  is  often  considerable 
mucus  rattling  in  the  trachea,  without  any  expectoration.  The  sudden 
stopping  of  cough  and  expectoration  in  consequence  of  unconscious- 
ness, often  accompanied  with  weakness,  is,  therefore,  particularly  in 
many  diseases  of  the  lungs,  as  in  pneumonia,  a  bad  sign  ;  in  phthisis, 
also,  it  sometimes  denotes  approaching  death.  It  has  already  been 
mentioned  that  cough  may  disappear  as  a  result  of  paralysis  of  the 
muscles  concerned  in  coughing. 

We  can  draAV  no  diagnostic  conclusion  from  the  frequency  of  the 
cough.     Regarding  the  time  of  day  when  it  is  most  apt  to  occur, 


166  SPECIAL  DIAGNOSIS. 

frequently  in  phthisis,  and  also  in  chronic  bronchitis,  this  regularly 
occurs  soon  after  waking. 

Dry  cough  is  one  that  is  not  accompanied  with  expectoration.  It 
is  generally  weak :  "slight  cough"  (especially  in  the  beginning  of 
phthisis,  also  as  "pleural  cough"  (see  above);  but  also  "nervous," 
from  bad  habit). 

There  is  a  cough  with  tough  expectoration,  difficult  to  be  dislodged, 
brought  up  generally  after  a  long  series  of  labored  eiforts ;  at  the  end 
there  is  generally  hawking ;  the  patient  often  pauses  to  rest,  and  then 
continues  to  cough  until  a  final  hawking  and  expectoration,  as  in 
emphysema  with  tough  bronchitis,  and  in  croupous  pneumonia. 

Moist  cough  with  fluid  (more  purulent)  expectoration  is  easier, 
"looser."  Here  it  is  often  remarkable  what  a  quantity  of  sputum  is 
thrown  off,  as  from  a  cavity — sometimes  from  two  eflbrts  at  coughing. 
Moreover,  with  patients  who  are  weak  and  very  miserable,  often  a 
series  of  efforts  are  necessary,  which  efforts  then  generally  end  with 
hawking  (phthisis  in  extreiiiis). 

In  whooping-cough  the  cough  occurs  in  pronounced  paroxysms. 
Here  the  inspiration  is  noisy,  because  it  must  be  taken  as  quickly  as 
possible,  and  also  because  the  glottis  is  narrowed  by  swollen  mucous 
membrane.  In  consequence  of  the  prolonged  effort  at  coughing,  of 
the  constantly  increasing  intra-thoracic  pressure,  and  the  diminished 
breathing,  which  causes  a  disturbance  of  the  interchange  of  gases  and 
blood- stasis,  there  is  cyanosis ;  here,  as  otherwise  in  long-continued 
labored  effbrts  at  coughing,  especially  in  phthisis,  they  finally  very 
frequently  end  in  vomiting.  Severe  attacks  of  coughing,  moreover, 
result  from  swallowing  the  wrong  way,  as  in  paralysis  of  the  throat 
from  various  causes.  Unconscious  patients  often  swallow  the  wrong 
way  without  any  cough. 

The  tone  of  the  cough  may  be  unnaturally  deep  and  rough,  like  the 
voice,  in  ulceration  of  the  larynx ;  in  stenosis  of  the  larynx  it  is 
either  a  short  stenosis  sound,  or  rough  and  bellowing  (the  latter  with 
children  with  diphtheria  or  false  croup) ;  in  continued  aphonia  the 
cough  is  sometimes  toneless,  sometimes  remarkably  rough  and  sharp. 

Hawking  only  brings  up  masses  lodged  in  the  pharynx,  larynx,  or 
the  upper  part  of  the  trachea ;  but  it  must  not  be  understood  that 
what  is  thus  brought  up  is  formed  at  these  locations;  it  may  be 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.       167 

brought  to  the  lower  part  of  the  larynx  by  previous  cough  or  by  the 
motion  of  the  ciliated  epithelium. 

EXPECTORATION,    SPUTUM. 

By  these  terms  is  understood  all  that  is  brought  up  from  the  air- 
passages  by  coughing  and  hawking.  According  to  the  existing 
disease,  they  are  formed  from  the  secretions  of  the  laryngeal,  tracheal, 
and  bronchial  mucous  membrane,  from  the  contents  of  the  alveoli  of 
the  lungs,  and,  lastly,  from  the  contents  of  pathological  cavities  of 
the  lungs,  or  from  the  lung  tissue.  In  rare  cases  purulent  exudations 
from  the  pleural  cavities,  from  rupture  of  the  pleura,  may  reach  the 
air-passages  and  appear  as  sputum;  still  more  rarely,  by  communication 
of  the  oesophagus  or  rupture  of  an  aneurism,  particles  of  food  or  blood 
may  pass  this  way.  The  secretion  of  the  mucous  membrane  or  of  the 
glands  of  the  throat,  of  the  mouth,  of  the  nose,  and  also  other  sub- 
stances from  these  locations  (as  blood,  microorganisms,  particles  of 
food),  mingled  in  various  proportions  with  the  expectoration,  may  give 
rise  to  error.  Expectoration  may  be  entirely  wanting,  even  when  the 
material  for  expectoration  may  be  present  in  the  air-passages  in  con- 
siderable quantity,  when  there  is  absence  of  cough,  or  when  the  cough  is 
feeble  (see  page  165) ;  finally,  it  may  sometimes  happen  in  all  diseases 
of  the  respiratory  organs  that  there  is  either  no  cough  at  all,  or  only  a 
dry  cough.  It  is  not  unimportant  to  note  that  blood  escaping  from 
the  stomach  by  vomiting  may  give  occasion  for  swallowing  and  then 
be  expelled  by  coughing ;  but,  on  the  other  hand,  in  hemorrhage  of 
the  lungs  a  part  of  the  blood — sometimes  a  considerable  quantity — 
may  be  swallowed,  and  may  give  rise  to  symptoms  of  hematemesis. 

When  possible,  it  is  best  to  collect  the  expectoration  in  a  transparent 
glass  vessel  (as  a  matter  of  fact,  we  may  readily  understand  that  we 
shall  generally  have  to  employ  a  non-transparent  receptacle).  As 
much  as  possible,  mixture  with  other  substances,  as  vomited  matters, 
is  to  be  avoided.  A  white  porcelain  plate,  with  one-half  of  its  surface 
blackened  with  asphalt,  enables  one  to  scrutinize  more  exactly  the 
expectoration.  The  expectoration  upon  both  halves  of  the  plate  is  to 
be  examined,  and,  in  order  to  separate  it  or  to  remove  a  portion  for 
microscopical  examination,  we  employ  a  pair  of  microscopic  needles. 


Ig8  SPECIAL  DIAGNOSIS. 

1.   Gfeneral  Characteristics  of  the  Expectoration. 

We  must  take  into  consideration  the  quantity,  reaction,  consistence, 
or  form  (here  are  included  also  the  quantity  of  air  mingled  with  it, 
and  its  arrangement  in  layers),  its  color  and  transparency,  and, 
finally,  its  odor. 

The  quantity  of  expectoration  changes  with  the  amount  of  material 
which  is  in  a  condition  to  be  thrown  off  (and  this  differs  very  much 
with  different  diseases)  and  with  the  strength  of  the  cough.  We  have 
already  referred  several  times  to  the  influences  that  determine  this. 
In  general,  patients  with  certain  forms  of  bronchitis  (broncho-blennor- 
rhcea)  and  with  cavities,  especially  those  with  bronchiectasis,  have  the 
most  abundant  expectoration ;  it  may  amount  to  one  or  two  litres  a 
day.  Sudden  marked  increase  of  expectoration  occurs  with  the 
rupture  of  empyema  into  the  lungs. 

When  not  much  contaminated  with  vomited  matter  the  reaction  of 
the  expectoration  is  always  alkaline. 

From  the  above-mentioned  general  peculiarities  (consistence,  form, 
color,  except  only  the  odor)  we  may  recognize,  according  to  its  chief 
constituents,  in  which  class  the  expectoration  belongs.  Accordingly, 
we  distinguish : 

Mucous  sputum. 

Muco-purulent  sputum. 

Purulent  sputum. 

Serous  sputum. 

Bloody  sputum. 

Mucous  sputum.  This  is  either  quite  glassy  and  transparent  or 
whitish-gray,  generally  with  some  consistence,  and  tough ;  if  more 
fluid,  then  it  consists  chiefly  of  saliva.  It  occurs  in  the  first  stage  of 
acute  bronchitis  from  the  very  slight — what  may  be  called  the  physior 
logical — secretion  of  mucus  in  the  trachea.  Very  often  its  source  is 
higher  up  in  the  pharynx. 

Muco-purulent  sputum.  It  consists  of  a  mixture  of  mucus  and  pus 
in  varying  proportions.  The  latter  is  recognized  by  its  yellowish- 
green  color  and  its  want  of  transparency.  It  may  be  distributed 
through  the  mucus  in  small  particles  or  strings,  or  it  may  form  larger 
flocks  or  balls  held  together  by  mucus  ;  the  latter,  placed  in  water,  are 
bullet-shaped;  spread  out  upon  the  bottom  of  an  empty  glass,  they 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.       169 

sometimes  flatten  out  in  circular  form  (coin-shaped  sputa  in  case  of 
cavities,  but  sometimes,  also,  in  ordinary  purulent  bronchitis,  as  in 
measles) ;  finally,  in  the  scanty,  spongy  mucus  with  slight  consistence, 
the  pus  of  the  separate  sputa  may  run  together  ("confluent  sputa"). 
If  the  sputum  contains  many  air-bubbles,  then  these  cause  the  separate 
lumps  and  balls  to  float  in  the  watery  part  of  the  sputum  (serous  fluid, 
or  very  watery  mucus,  or  saliva).  Mucus  in  three  layers  consists  of 
an  upper  layer  of  masses  and  balls,  which  the  air-bubbles  cause  to  swim 
and  from  which  hang  down  into  the  second  layer,  consisting  of  watery 
mucus  and  serum,  slimy,  purulent  strings ;  on  the  bottom  is  a  layer 
entirely  confluent,  like  a  deposit  of  decomposed  pus  (fetid  bronchitis, 
gangrene  of  the  lung). 

Purulent  sputum  consists  of  almost  pure  pus,  whose  source  is  either 
an  abscess  of  the  lung  which  has  given  way,  or  an  empyema.  Some- 
times almost  pure  pus  may  be  coughed  up  when  there  is  a  sudden 
very  considerable  discharge  from  a  cavity.  As  it  traverses  the  air- 
passages,  there  is  always  some  mucus  mixed  with  it. 

8erous  sputum  is  a  special  peculiarity  of  the  sputum  of  oedema  of 
the  lungs.  It  is  very  fluid,  but  not  so  much  so  as  blood-serum,  being 
mixed  with  mucus.  It  consists  of  blood-serum,  and,  hence,  contains 
albumin  ;  for  this  reason  it  retains  air  vesicles  for  a  long  time,  as  do 
all  fluids  containing  much  albumin  ;  it  is  markedly  frothy.  It  is 
either  a  quite  light  gray  and  transparent,  or,  as  is  frequently  the  case, 
like  beef-juice,  owing  to  a  slight  admixture  with  blood;  when  con- 
taining much  blood,  it  is  the  color  of  prune-juice  (oedema  of  the 
lungs  with  pneumonia). 

Bloody  sputum.  All  of  the  varieties  of  sputum  previously  mentioned 
may  be  mixed  with  blood.  Slight  mixture  of  blood  is  seen  in  the 
expectoration  of  tough  mucus  as  bloody  streaks  (generally  from  the 
upper  air-passages,  often  from  the  throat  or  nose,  but  yet  sometimes 
from  the  lungs  or  the  smallest  bronchial  tubes,  as  in  pneumonia). 
A  small  quantity  of  blood  with  partial  escape  of  coloring  matter  of  the 
blood,  intimately  mixed  with  tough,  glassy  mucus,  colors  the  sputum 
uniformly  bright  red  with  a  greenish  tinge,  or,  by  transformation  of 
the  coloring  matter  of  the  blood,  makes  it  yellowish-red,  rusty,  even 
greenish  (all  of  these  with  pneumonia).  In  muco-purulent  sputum, 
blood  appears  either  in  streaks  or  as  little  spots,  as  in  phthisis,  or 
intimately  mixed  :  the  pus  is  then  reddish-yellow,  brownish-yellow,  or 


170  SPECIAL  DIAGNOSIS. 

more  markedly  reddened  (not  infrequent  with  cavities).  When  there 
is  only  a  small  amount  of  blood,  serous  sputum  is  the  color  of  beef- 
juice. 

If  there  is  considerable  hemorrhage  with  the  expectoration,  it  is 
markedly  colored  with  blood ;  sometimes  there  may  apparently  be  no 
sputum,  but  fluid  blood  may  be  expectorated  in  a  liquid  state,  coagu- 
lating afterward.  This  is  described  as  hemoptysis.  When  a  pulmonary 
hemorrhage  is  quickly  coughed  up,  the  blood  is  bright-red  and  frothy 
from  being  mixed  with  the  sputum  ;  but  sometimes  it  gushes  out  in  such 
quantity  that  there  is  no  cough.  It  is  distinguished  from  blood  that 
comes  from  the  stomach  in  that  the  latter,  from  longer  stagnation  and 
from  the  effect  of  the  secretion  of  the  stomach,  generally  is  darker, 
quite  brown,  like  coffee-grounds  ;  besides  which  it  is  often  mixed  with 
food  and  has  an  acid  reaction.  Yet  the  blood  from  the  lungs,  though 
only  when  there  is  considerable  quantity,  may  be  also  dark,  even 
black-red,  if  it  ha;5  stagnated  in  the  lungs  or  air-passages  :  thus,  a 
patient  who  has  had  an  hemoptysis  may  continue  for  a  whole  day  to 
throw  off  markedly  bloody  sputum,  which  becomes  more  and  more 
dark  in  color. 

Semorrhage  of  the  lungs  occurs  very  much  more  frequently  with 
tuberculosis  than  from  other  causes.  In  this  disease  there  occur  all 
varieties  of  hemorrhage,  from  the  scarcely- visible  particles  of  blood  or 
a  slight  coloring  of  the  purulent  discharge  from  a  cavity  to  the  pro- 
fuse, almost  immediately  fatal  hemorrhage.  Moreover,  in  infarction 
of  the  lungs  there  may  be  bloody  sputum,  or  even  pure  blood  may  be 
discharged.  Croupous  pneumonia  and  cedema  of  the  lungs  are  gen- 
erally accompanied  with  slight  quantities  of  blood  intimately  mixed 
with  the  sputum. 

Sometimes  it  is  perfectly  easy  to  diagnose  hemorrhage  of  the  lungs, 
and  again  it  is  extremely  difficult.  Particles  and  streaks  of  blood 
occurring  in  the  midst  of  purulent  material  are  very  suspicious.  If 
they  occur  with  gray  mucus,  it  is  generally  quite  unimportant  (pharynx, 
nose)  ;  but  when  there  is  considerable  hemorrhage,  there  may  be  doubt 
as  to  whether  the  blood  comes  from  the  stomach  or  lungs  if  the  blood  is 
expectorated  very  rapidly,  and  so  is  yet  bright-red,  and  if,  during  the 
act  of  vomiting,  some  blood  is  aspirated  and  causes  cough.  On  the 
other  hand,  blood  from  the  lungs  may  seem  to  come  from  the  stomach 
if,  from  stagnation,  it  is  unusually  dark,  or  if  a  part  of  it  is  swallowed 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.        171 

and  then  vomited.  Blood  from  the  nose  and  throat,  when  the  patient 
is  unconscious  or  asleep,  may  be  drawn  into  the  air-passages,  and 
then,  after  considerable  has  accumulated,  be  coughed  up,  but  more 
frequently  it  flows  into  the  stomach.  In  the  latter  case,  by  inspection 
of  the  throat  we  may  sometimes  see  a  streak  of  blood  marking  the 
track  upon  the  posterior  wall  of  the  pharynx.  In  all  such  cases  a 
decision  is  to  be  reached  by  the  most  careful  examination  of  both  the 
lungs  and  stomach. 

A  peculiar  sputum,  like  raspberry  jelly,  is  observed  in  cases  of 
tumor  of  the  lungs.  Sometimes  in  hysteria  there  is  an  expectoration 
from  the  pharynx  or  oesophagus  of  a  peculiar  raspberry  red,  which 
may  mislead  one  (recently  described  by  E.  Wagner). 

The  odor  of  sputum  is  ordinarily  stale  ;  when  it  is  scanty,  it  is  often 
oiFensive  from  mixture  with  the  secretions  of  the  mouth,  especially 
among  the  lower  classes  or  when  the  patient  is  very  sick.  Purulent 
sputum  from  a  cavity,  if  it  has  been  long  retained,  may  be  putrid  or 
have  a  peculiar  putrid-rancid  odor  (only  with  phthisical  patients  in 
extremis).  In  cases  of  fetid  bronchitis,  bronchiectasis,  and  gangrene 
of  the  lungs  a  more  marked  and  very  characteristic,  sharper  and  more 
penetrating,  quite  offensive  odor  from  the  muco-purulent  sputum 
decomposing  in  the  air-passages,  is  commonly  present;  but  in  the 
last-mentioned  disease  it  may  be  entirely  wanting  (^'^ odorless  gan- 
grene ").  Offensive  odor  of  sputum  may  sometimes  be  caused  by 
decomposition  of  particles  of  food  in  the  mouth  or  by  offensive  plugs 
in  the  lacunse  of  the  tonsils,  and  thus  one  may  be  entirely  deceived. 

2.  Foreign  Substances  in  the  Sputum  which  are  Visible  to  the 
Unaided  Eye? 

The  inhalation  of  coal-soot  (most  frequently  by  those  especially 
exposed  to  it,  but  also  by  all  dwellers  in  cities)  colors  the  sputum,  in 
streaks   or  diffusely,   blackish-gray.     When  iron-dust  is  inhaled,  it 

1  Nowadays  the  microscopical  examination  of  the  expectoration,  with  its  brilliant, 
but  partial^  results,  is  carried  to  such  an  extent,  and  so  calls  the  chief  attention  to  this 
secretion,  that  it  seems  necessary  to  draw  attention  to  the  importance  of  examining  it 
with  the  unaided  eye.  Carefully  conducted,  it  not  infrequently  brings  the  physician, 
in  difficult  cases,  directly  to  a  correct  diagnosis,  beside  facilitating  the  use  of  the  micro- 
scope in  showing  how  to  find  the  right  spots.  Hence,  this  section  is  introduced  with 
careful  consideration. 


172  SPECIAL  DIAGNOSIS. 

colors  the  sputum  quite  black,  or  ochre-yellow  and  red  (see  on  this 
point,  also,  under  Microscopical  Examination).  When  the  sputum  is 
scanty  it  is  more  deeply  colored  than  when  it  is  abundant,  since  in 
the  former  case  the  coloring-matter  is  more  concentrated. 

We  have  already  referred  to  the  addition  of  blood.  The  presence 
of  hcematoidin  is  sometimes  evident  to  the  unaided  eye  by  a  yellowish 
or  brownish-red  color  in  separate  spots ;  it  occurs  in  the  lungs  when 
there  is  disease  of  the  heart,  in  cases  of  abscess  of  the  lungs,  and  in 
empyema  (confirmation  by  the  microscope,  see  page  181). 

In  icterus  the  bile  pigment  is  sometimes  present  in  the  expectora- 
tion ;  it  has  often  been  observed  by  myself  (as  well  as  others)  that  in 
pneumonia  with  icterus,  more  particularly,  it  colors  the  sputum  a 
distinct  yellow-green  or  green. 

In  abscess  of  the  lung  we  observe  lung-tissue  in  the  shape  of  larger 
or  smaller  pieces.  These  "lung  sequestra"  may  sometimes  be  very 
large — 2.5  cm.  long.  (Salkowski,  of  Leyden).  Pieces  of  cartilage 
from  the  trachea  or  the  bronchial  tubes,  in  deep  ulceration  and  the 
accompanying  perichondritis  of  these  organs,  will  sometimes  be 
coughed  up. 

Fibrinous  tubes,  formed  in  the  bronchial  tubes  as  a  result  of  fibrinous 
inflammation  there,  may  form  a  more  or  less  considerable  part  of  the 
expectoration.  We  may  have  a  firm  cast  of  an  entire  dichotomous 
ramification  of  a  laro;e  bronchial  trunk  even  to  the  finest  branches 
(even  to  the  alveolar  tubes  and  the  alveoli  ?) ;  more  frequently  they 
come  from  the  smaller  bronchi,  and  are  only  divided  two  to  five  times. 
Very  often  these  casts  are  thrown  off  while  they  are  fresh,  as  is  evident 
by  their  white  color ;  they  are  also  often  yellowish-brown,  or  else 
reddish,  from  the  addition  of  blood.  They  are  often  found  as  irregular 
lumps  covered  with  mucus  or  small  flakes,  so  that  the  inexperienced 
do  not  recognize  their  true  character.  In  order  to  make  them  out,  it 
is  necessary  to  isolate  them  by  shaking  them  up  with  water  in  a  test- 
tube.  Generally  they  exist  only  as  casts  of  the  smaller  bronchial 
tubes  in  croupous  pneumonia,  and  are  most  abundant  before  and 
during  resolution  ;  as  dense  large  casts  in  chronic  croupous  bronchitis, 
and  in  acute  croupous  bronchitis,  in  consequence  of  laryngeal  and 
tracheal  croup. 

Complete  casts  of  the  trachea,  and  even  of  the  larynx,  are  some- 
times thrown  ofi"  in  croup.     Casts  wholly  from  the  smallest  bronchial 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS. 


173 


tubes,  or,  in  reality,  from  the  alveolar  channels,  occur  in  bronchial 
asthma ;  and,  more  rarely,  in  croupous  pneumonia  as  the  so-called 


Fig.  26. 


Large  bronchial  coagulum  (chronic  fibrinous  bronchitis).     (After  Riegal.) 


spirals.     In  the  expectoration  their  smallest  forms  constitute  dimin- 
utive gray  transparent    or  whitish    opaque    flocks    or   lumps   which 


174  SPECIAL  DIAGNOSIS. 

frequently,  on  close  examination,  look  like  fine  hairs  rolled  together. 
(On  these  bodies,  see  p.  179.) 

Regarding  echinococcus  bladders,  and  the  exotic  Dhtoma  pulmo- 
num  (Balz),  found  in  the  sputum,  see  under  Microscopical  Examination. 

Of  the  crystals  occurring  in  the  sputum  (which,  of  course,  can  only 
be  perfectly  made  out  by  examination  with  the  microscope),  sometimes 
by  careful  examination  with  the  naked  eye  two  forms  may  possibly  be 

Fig.  27. 


Bronchial  coagulum,  natural  size,  with  croupous  pneumonia.  In  this  disease  the 
small  forms  are  very  frequent,  the  large  ones  very  rare,  but  frequent  with  chronic 
fibrinous  bronchitis. 

recognized.  In  the  fetid  sputum  in  three  layers  (fetid  bronchitis  and 
gangrene  of  the  lungs)  there  exist  peculiar  grayish-yellow,  very 
offensive  lumps,  which  may  be  barely  visible,  or  may  be  as  large  or 
larger  than  lentils;  these  lumps  inclose  fat-crystals  (see  p.  181). 
These  same  bodies  occur  as  offensive  plugs  from  the  lacunae  of  the 
tonsils,  although  never  in  so  large  a  quantity  as  in  the  other  condi- 
tions. Hence,  when  they  are  found  in  the  sputum  Ave  must  always 
carefully  examine  the  tonsils. 

Further,  in  chronic  croupous  bronchitis  and  in  hronchial  asthma 
there  are  found  embedded  in  the  sputum,  sometimes  adhering  to  the 
concretions,  peculiar,  small  bodies,  yelloAvish  kernels,  like  grains  of 
sand,  which  easily  strike  the  practised  eye ;  these,  generally  numerous, 
are  the  so-called  Charcot-Leyden's  crystals  (see  p.  181). 

It  remains   to  mention   some  fungi  found  in  the  sputum,  whose 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.        i;'5 

presence  may  be  indicated  by  the  macroscopical  examination,  but  this 
examination  would  be  without  diagnostic  value  unless  confirmed  by 
the  microscope.  Different  kinds  of  mould  (especially  Aspergillus 
fumigatus)  are  very  rarely  found,  except  as  a  pathological  result,  and 
generally  in  phthisical  cavities,  which  are  noticed  as  gray  or  greenish, 
little  collections ;  muguet  (see),  as  white  tufts  almost  always  arising 
from  the  mouth  and  throat  (hence,  these  are  to  be  carefully  examined) ; 
leptothrix  buccalis,  sometimes  mixed  in  the  mouth  with  expectoration  ; 
if  it  stands  some  time  in  a  Warm  place,  developing  as  a  yellow  coating 
— all  exceptional  appearances  of  slight  importance. 

The  finding  of  actinomyces  in  the  expectoration  is  of  greater  im- 
portance, but  of  yet  greater  rarity.  It  can  be  recognized  by  the  naked 
eye  by  the  little  kernels  of  uniform  size,  shaped  like  millet-seeds, 
greenish-yellow  or  yellowish-white,  sometimes  somewhat  glassy  (I 
have  seen  them  in  one  case) ;  of  course,  they  are  only  to  be  accurately 
recognized  by  the  microscope. 

Also,  we  may  sometimes  conjecture  the  presence  of  the  tubei^cle 
bacillus  with  the  naked  eye  (which  makes  the  microscopical  examina- 
tion easier),  by  the  presence  of  yellowish,  generally  flat  lumps — 
"lentils  " — in  the  sputum  from  cavities,  which,  besides,  usually  con- 
tains many  elastic  fibres  (see  p.  177) ;  and,  also,  although  much  more 
rare,  if  there  are  small  white  (scarcely  visible)  scales,  very  like  those 
of  which  the  artificial  pure  culture  of  the  bacillus  tuberculosis  consists. 
Both  elements,  especially  the  latter,  usually  contain  or  consist  of 
masses  of  bacilli.  It  is  very  easy  to  be  deceived  by  the  admixture  of 
food-particles.  Chiefly  is  this  the  case  from  the  small  white  lumps  of 
coagulated  milk  (which  not  infrequently  contain  fat-crystals)  and 
minute  particles  of  bread. 

3.  Microscopical  Examination  of  the  Sputum. 

Small  particles  are  placed  under  a  glass  cover,  which  is  to  be  only 
moderately  pressed.  It  is  to  be  examined  with  a  No.  7  or  8 
Hartnack,  or  E  or  F  Zeiss. 

In  all  mucous  and  muco-purulent  sputum  there  are  threads  of  mucus 
and  mucous  corpuscles ;  the  former  are  more  sharply  defined  the  tougher 
the  mucus  is.     In  pneumonia  and  asthma  they  are  often  spiral,  and 


i76  SPECIAL  DIAGNOSIS. 

in  these  diseases  they  pass  by  imperceptible  gradations  over  into  the 
finest  and  most  delicate  fibrinous  formations.     (See  Spirals.) 

White  blood- corpuscles  duVQ  found  in  all  expectoration,  but  in  much 
greater  numbers  in  the  purulent  parts.  They  are  generally  of  various 
sizes,  granular,  not  infrequently  filled  with  drops  of  fat  and  myelin, 
or  contain  particles  of  soot ;  and  lastly,  and  more  rarely,  minute 
lumps  of  heematoidin  (see). 

Red  blood-corpuscles  are  found  in  the  diiferent  kinds  of  bloody 
sputum,  generally  with  the  form  well  preserved,  but  often  paler,  even 
as  rings ;  when  the  sputum  has  been  retained  for  a  long  time  they 
are  granular. 

Epithelium.  Flat  epithelial  cells  from  the  mouth  are  a  common 
ingredient  of  the  sputum.  They  are  easily  recognized  by  their  size 
and  thinness,  which  manifests  itself  by  numerous  cracks  and  folds. 
Flat  epithelium,  Avhich  probably  comes  from  the  oesophagus,  occurs  in 
large  clusters  in  the  so-called  bloody  sputum  of  hysteria. 

Fig.  28. 


Epithelium  from  the  sputum,     a.  Flat  epithelium  from  the  mouth.    6.  The  so-called 
alveolar  epithelium,  containing  little  drops  of  fat  and  myelin,    d.  A  red  blood-corpuscle. 

Changed  cylindrical  epithelium  of  the  air-passages  in  the  form  of 
mucous  and  goblet  cells  are  observed  in  all  cases  of  catarrh  of  the 
trachea  or  of  the  bronchi,  and  sometimes  in  large  numbers.  On  the 
other  hand,  it  is  rare  to  find  these  epithelial  cells  in  their  original 
condition,  with  homogeneous  protoplasm,  with  bladder-like  nucleus, 
covered  with  cilia;  and  still  more  rare  to  obtain  the  motion  of  the 
cilia,  or  to  find  it  responsive  to  heat.  The  possible  origin  of  these 
cells  in  the  nose  is  not  to  be  overlooked.     They  have  diagnostic  value. 

The  so-called  alveolar  epithelium  (see  Fig.  28)  was  formerly  con- 
sidered an  important  constituent  of  the  sputum.  But  it  is  neither 
possible  to  affirm  its  source  nor  to  give  its  diagnostic  value.  There 
are  elliptic,  or  round,  not  infrequently  somewhat  flattened,  cells  with. 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.        177 

an  often  indistinguishable  nucleus  (made  visible  by  the  addition  of 
acetic  acid),  larger  than  the  ordinary  white  blood-corpuscle.  The  proto- 
plasm is  fine  or  coarsely  granular,  sometimes  filled  with  drops  of  fat 
or  myelin  (Virchow) ;  also  we  may  see  complete  fatty  degeneration 
with  formation  of  large  fat  and  myelin  drops.  These  cells  contain 
particles  of  coal  or  iron  dust  (the  latter  made  dark  green  by  sulphide 
of  ammonium,  blue  by  yellow  prussiate  of  potash  and  muriatic  acid). 
In  the  lungs  of  cases  that  have  died  with  heart  disease  they  are  found 
filled  with  lumps  of  hgematoidin. 

This  alveolar  epithelium  occurs  in  bronchitis  and  all  kinds  of  acute 
and  chronic  pneumonia,  hence  does  not  have  any  diagnostic  value. 
Its  epithelial  character  is  not  at  all  constant.  I  think  it  quite  prob- 
able that  it  is  mostly  or  altogether  made  up  of  white  blood-corpuscles, 
enlarged  by  metamorphosis,  or  their  protoplasm,  and  partly  by  ab- 
sorption of  small  particles.  In  part,  also,  this  may  come  from  the 
deeper  layer  of  the  bronchial  epithelium  (Panizza,  Fischl,  Senator). 
On  the  other  hand,  the  so-called  cells  of  heart  disease  containing 
haematoidin  are  significant  in  recognizing  the  lungs  of  cases  that  have 
died  from  disease  of  the  heart. 

Elastic  threads  are  an  important  constituent  of  sputum,  since  they 
infallibly  show  the  destruction  of  lung  tissue  (less  frequently  of  the 
tissue  of  the  bronchi),  but  still  more  because  they  indicate  such  a 
severe  disease  of  the  lungs  often  before  there  are  physical  signs. 
They  occur  in  tuberculosis,  gangrene,  abscess  of  the  lungs.  They 
generally  have  a  double  outline ;  now  and  then  there  are  branching 
fibres,  which  have  a  serpentine  course  or  large  irregular  curves. 
They  generally  lie  in  bundles,  and  often  show  the  structure  of  the 
lung-vesicles. 

They  always  exist  in  clusters  and  with  a  remarkably  alveolar 
arrangement  in  the  shreds  of  lung  tissue  in  abscess  of  the  lungs,  and 
when  there  is  suppurating  gangrene ;  further,  almost  always  in  the 
so-called  "lintels"  of  tubercular  sputum.  When  elastic  threads  occur 
singly,  which  may  be  in  all  the  conditions  named,  it  is  very  difficult 
to  say  which  is  their  special  cause.  Then,  also,  it  is  not  easy  to 
distinguish  them  from  fat  crystals  (see),  and  farther  from  elastic  fibres 
in  food.  Besides,  since  the  discovery  of  the  bacillus  tuberculosis  their 
importance  for  the  early  diagnosis  of  phthisis  has'(lis'appeared ;  but 

12 


178 


SPECIAL  DIAGNOSIS. 


for  determining  wliether  we  have  a  more  or  less  destructive  form  of 
phthisis  they  are  as  valuable  as  ever. 

To  obtain  elastic  fibres,  when  they  are  not  present  in  quantity,  a 


Fig.  29. 


Elastic  fibres.     (After  Struempell.) 
Fig.  30. 


Curschmann's  spirals,  natural  size       (After  Cueschmann.) 

portion  of  sputum  is  boiled  with  an  equal  quantity  of  an  8  to  10  per 
cent,  solution  of  caustic  potash ;  then  the  jelly-like  mass  is  to  be  diluted 
with  water  and  allowed  to  stand  for  twenty-four  hours.     The  elastic 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.        ]79 


fibres,  as  distinct  organic  substances,  settle  to  the  bottom,  but  are  much 
swollen  and  not  readily  distinguished  from  fibres  of  the  food. 

In  individual  cases  of  gangrene  of  the  lungs,  but  by  no  means  in 
all,  elastic  fibres  may  be  wanting:  possibly  they  may  be  destroyed  by 
the  action  of  a  ferment  (Traube)  [see  p.  190].  Moreover,  simple 
gangrene  of  the  lungs  is  rare  ;  we  generally  have  a  suppurating 
gangrene,  and  this  can  hardly  fail  to  furnish  the  shreds  of  lung 
tissue  previously  described. 

Spirals  (Leyden,  Curschmann,  Zenker).  They  exhibit  the  finest 
forms  of  bronchial  products,  and  hence  correspond  probably  to  a 
(fibrinous)  catarrh  of  the  smallest  bronchial  tubes.  With  some  prac- 
tice they  are  recognizable  by  the  naked  eye  (Fig.  30),  and  under  a 
glass  cover  Avhen  somewhat  spread  out  by  very  slight  pressure,  even 
without  any  amplification,  there  may  be  seen  a  spiral  twist,  and  often 
in  the  centre  a  bright   line  which  is  generally  wavy.     When  very 


Fig.  31. 


Fig.  32. 


Fig.  33. 


Curschmann's  spirals,     a.  Central  fibre.     (After  Cubschmanv.) 

slightly  magnified  (best  seen  with  a  simple  microscope  of  good  powder) 
we  can  plainly  see  the  spirals  formed  out  of  fibres  wound  like  a  cork- 
screw; and  further,  we  can  see  the  streak  in  the  middle,  the  central 
thread,  as  a  homogeneous,  a  somewhat  bluish-tinted  structure,  coursing 
exactly  along  the  middle  of  the  tube.  This  central  fibre,  which  may 
be  entirely  wanting,  does  not  exhibit  a  sharply-defined  contour,  no 
matter  how  much  it  is  magnified  or  how  the  focus  of  the  microscope 
is  adjusted.  It  is  probably  not  a  material  structure,  but  an  optical 
image  of  a  space-cavity  or  of  a  strand  of  tightly-twisted  fibres  in  the 
centre  of  the  spiral.  Regarding  the  peculiar  finely  granular  cells 
accompanying  them,  and  Charcot-Leyden's  crystals,  see  page  182. 


180 


SPECIAL  DIAGNOSIS. 


Curschmann  has  affirmed  that  these  spirals  have  an  important  diag- 
nostic, and  indeed  a  causal  relation  to  bronchial  asthma  ("bronchio- 
litis exudativa,"  Curschmann).  They  are  especially  abundant  in 
these  cases,  in  many  patients  only  at  the  time  of  the  attack,  so  that 
as  the  attack  passes  off,  they  are  excreted  in  quantity.  Rarely,  and 
without  diagnostic  importance,  they  are  present  in  croupous  pneumonia 
(0.  Vierordt,  von  Jaksch,  and  others).  I  saw  them  in  a  case  of  very 
chronic  tuberculosis  of  the  lungs.  According  to  Pel,  they  consist 
largely  of  mucin. 

Starch  corpuscles  They  are  often  found  in  Jiemorrliage  of  the 
lungs  (Friedreich),  and  in  gangrene  (von  Jaksch),  but  are  as  yet 
without  significance. 

Crystals.  Crystals  of  hgematoidin  are  brownish-yellow,  if  pure,  of 
a  shining  color,  rhombic  plates,  or  fine  needles,  and  these  single,  or 
two  or  three  crossed,  or  in  tufts.  The  crystalline  formation  may  also 
occur  as  grains  and  lumps ;  not  infrequently  in  the  centre  is  a  white 
blood-corpuscle,  and  it  may  be  that  the  needles  are  arranged  with 
their  points  standing  out  from  the  cells. 


Fig.  35. 


Crystals  of  haematoidin. 


Needles  of  fatty  acids.     (After 
Struempell.) 


They  indicate  that  blood  has  been  long  retained :  in  gangrene  with 
formation  of  abscess ;  in  the  pus  of  empyema  which  has  perforated  a 
Ions:  time  before,  as  in  one  case  that  came  under  mv  observation  of  a 
slow  hemorrhaoje  into  the  lungs  from   a  thoracic    aortic   aneurism. 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS        181 

Sometimes    there   are    spots   macroscopically   visible    when    there  is 
hsematoidin  in  the  sputum,     (See  p.  172.) 

Crystals  of  fatty  acid  (margaric  acid  crystals,  see  Fig.  35).  They 
are  long,  thin,  slender  needles,  slightly  or  very  markedly  bent,  which 
are  found  singly,  in  large  bundles  or  nodules,  or  quite  irregularly 
arranged.  They  are  generally  distinguished  from  elastic  fibres  by 
the  uniformity  of  their  curving.  When  a  portion  of  sputum  is  dried 
in  the  air,  without  heat,  they  are  completely  dissolved  upon  the  addi- 
tion of  ether,  while  the  elastic  fibres  under  the  same  circumstances 
are  not  changed.  They  occur  generally  in  masses,  in  gangrene  of  the 
lungs  and  fetid  bronchitis,  and  especially  in  the  lumps  or  plugs 'pre- 
viously mentioned  (page  174) ;  they  are  also  found  in  the  plugs  which 
are  formed  in  inflamed  tonsils  (see) ;  finally,  they  may  occur  singly 
in  any  muco-purulent  sputum,  especially  after  standing  in  a  warm 
place  for  some  time. 

Fin.  3fi. 


Crystals  of  cholesterine,     (After  Struempell.) 


Oholesterine  crystals.  These  are  thin  rhombic  plates  with  the 
corners  cut  out,  which  become  green  and  then  red  when  treated  with 
dilute  sulphuric  acid  and  tincture  of  iodine.  They  are  sometimes 
found  in  old  perforating  pus^  also  in  tuberculosis. 

Charcot-Leyden  s  crystals.  These  are  slight,  somewhat  blue, 
shining,  elongated  octahedrals  of  great  variety  of  size,  sometimes 
visible  with  a  simple  microscope,  often  only  to  be  seen  with  a  No.  8 
Hartnack.  They  seem  to  be  identical  with  the  crystals  found  in  the 
blood  and  marrow  in  leukcemia,  also  sometimes  occurring  in  the  feces. 
They  probably  consist  of  a  mucous  substance  (Salkowski). 


182 


SPECIAL  DIAGNOSIS. 


As  a  sign  of  bronchial  asthma  they  are  of  great  diagnostic  impor- 
tance (see  Spirals) ;  they  then  occur  most  abundantly  during  and 
after  the  attacks  (Leyden).  They  are  less  frequently  found  in  acute 
bronchitis,  chronic  croupous  bronchitis,  and  tuberculosis. 


Fig.  37. 


Charcot-Leyden's  asthma  crystals.     (After  Riegel.) 


The  points  in  the  expectoration  of  asthma  where  these  are  found 
can  often  be  easily  recognized  with  the  naked  eye  as  dry  crumbs  (see 
p.  174).  They  are  very  often  mixed  with  peculiar,  fine,  granulated 
round  cells  which  look  as  if  filled  with  dust ;  at  the  same  time  with 
these  are  found  spindle-formed  figures  with  a  slight  glistening — a 
transition  stage  to  Charcot's  crystals  (?).  These  crystals  are  found 
especially  numerous  upon  and  in  the  "spirals,"  and  also  with  them 
these  spindle  formed  cells. 

In  isolated  cases  there  are  found  in  the  sputum  tyrosin  {fetid  bron- 
chitis, empyema,  according  to  Leyden),  oxalate  of  liyne  {diabetes, 
Fiirbringer;  asthma,  Ungar),  and  triple  phosphate  (see  chapter  on 
L'rine,  the  section  upon  these  substances). 

Animal  parasites.  We  may  have  whole  echinococcus  bladders  or 
their  fragments  (recognized  upon  cross-section   by  the  remarkable, 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.        183 


uniform  streaking),  and  also  the  hooks  of  the  scolices  in  the  sputum, 
in  case  one  of  these  parasites  enters  the  bronchial  tubes  by  rupture 
from  the  lungs  or  liver  (slight  increase  in  size). 


Fin.  38. 


^ 


Echinococcus.     (Scolices,  hooks,  after  Heller  ) 

The  (exotic)  Distoma  pulmonalum  (Balz)  which  causes  hemorrhage 
without  any  other  manifestation,  declares  itself  by  its  eggs  in  th^ 
sputum  (to  be  seen  by  the  simple  microscope). 

Fig.  39. 


Echinococcus  membrane,  cross-section  enlarged. 


Infusoria  (^Monas,  Cercomonas- Kannenherg)  are  found  in  gangrene ; 
they  are  seemingly  without  significance. 

Fungi  (for  the  macroscopic  evidences  of  the  presence  of  some  of 
them  see  p.  175). 


184  SPECIAL  DIAGNOSIS. 

LeptotJirix  huecalis  is  present  in  the  yellow  scum  arising  on  sputum 
that  has  been  standing  some  time,  as  has  already  been  mentioned, 
in  the  bronchial  plugs  in  putrid  bronchitis  (besides  crystals  of  fatty 
acids),  and  also  occurring  separately.  Either  it  is  first  mixed  in  the 
sputum  in  the  mouth,  or  it  has  entered  the  air-passages  from  the 
mouth ;  but  it  is  present  there  without  any  known  pathological 
significance.  Specific  reaction:  With  iodine  and  potass,  iod.,  it  is 
stained  blue-red.  [For  formula,  see  p.  189.]  Without  this  reaction 
it  may  be  confounded  with  elastic  threads,  even  with  fatty  acids  (see 
the  chapter  on  the  Digestive  Apparatus)*. 

Fig.  40. 


V 


^ 


Tubercle  bacilli  in  the  sputum,  first  colored  with  anilin-fuchsine  and  then  with 
methylene-blue.  Zeiss's  homog.  immersion  -^^,  Oc.  4,  camera  lueida  drawing.  Mag- 
nified about  1000  diam. 

Sarcina  pulmonalis  is  a  fungus  formed  by  division  from  developing 
endogenous  spores  (Hauser).  While  it  is  similar,  although  smaller, 
it  has  nothing  to  do  with  sarcina  ventriculi.  The  recent  views  upon 
their  frequent  presence  may  be  somewhat  questioned  (confounded  with 
Microccus  tetragenus  (?)  Fliigge).  It  has  no  known  pathological 
significance. 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS.        185 

Tuhercle  bacillus  (Koch).  This  generally  occurs  in  the  purulent 
parts  of  the  sputum  of  tuberculosis  of  the  lungs  or  trachea.  Excep- 
tionally it  may  be  mixed  with  the  sputum  from  the  throat  and  pharynx 
(nose),  in  case  a  tubercle  breaks  up  at  that  point.  They  are  generally 
very  abundant  in  the  so-called  "lintels,"  and  (rarely)  in  very  small 
white  scales  (see  p.  175).  These  split  fungi  are  straight  or  moderately 
— rarely  much — bent,  very  thin  rods  of  somewhat  variable  length,  2 
to  almost  4  [x} — that  is,  about  the  diameter  of  a  moderate-sized  white 
blood-corpuscle.  They  often  contain  spores.  On  account  of  their 
thinness  and  because  they  are  without  motion,  they  are  with  difficulty 
seen  in  the  sputum  unless  they  are  colored.  In  order  to  bring  them 
into  view  Ave  stain  them,  and  by  a  method  which  at  the  same  time 
produces  a  special  reaction,  and  so  a  very  certain  proof  that  it  is  the 
tubercle  bacillus  and  not  one  of  the  numerous  other  bacilli.  It  is  to 
be  magnified  600-400,  or,  for  those  accustomed  to  examine  for  it,  300 
diameters — that  is  to  say,  with  a  -j-^2"  Abbe  oil  immersion  lens,  or  a 
Hartnack  No.  8  or  at  least  No.  7. 

Methods.  I.  (Weigert-Ehrlich.)  With  perfectly  clean  needles 
we  place  some  sputum  upon  a  plate  with  a  black  surface,  and  there 
spread  it  out  with  the  needles.  From  this  is  selected  a  suitable  por- 
tion (see  above)  and  place  it  upon  a  glass  cover,  and  then  it  is  to  be 
broken  up  with  the  needles.  Upon  this  is  now  placed  another  glass 
cover  and  the  two  are  pressed  firmly  together.  What  is  squeezed  out 
upon  the  edges  is  to  be  washed  away,  and  then  the  two  glasses  are  to 
be  carefully  separated,  no  that  there  may  remain  upon  each  the  thinnest 
possible  layer,  equally  distributed.  These  are  then  laid  aside  to 
dry.  Then  20  drops  of  anilin  oil  are  thoroughly  mixed  with  a  small 
test-tube  full  of  distilled  water,  it  being  shaken  till  it  is  intimately 
mixed.  The  mixture  is  allowed  to  stand  for  a  short  time,  and  then 
some  of  it  is  to  be  filtered  through  a  moistened  filter  into  a  watch-glass. 
From  a  previously  prepared  concentrated  alcoholic  solution  of  fuchsine 
there  is  then  to  be  added  sufficient  to  make  the  mixture  opaque  or  to 
cause  a  slight  metallic  shimmer  to  appear  upon  the  surface ;  about  6 
drops  are  necessary.     Good  fuchsine  S.  is  necessary. 

The  glass  covers  are  allowed  to  dry  in  the  air,  and  then  each  is 
passed  three  times  through  the  flame  of  a  spirit-lamp  and  laid  in  the 

['  The  Greek  letter  fi  represents  one-thousandth  of  a  millimetre  {w^O.OOl  mm.),  and 
is  the  sign  of  a  micro-vdllimetre,  or  a  niicron-l 


18(5  SPECIAL  DIAGNOSIS. 

coloring-solution  with  the  sputum  side  down.  The  watch-glass, 
covered  over,  is  allowed  to  stand  for  twenty-four  hours,  or  it  is  slowly 
warmed  over  the  spirit-lamp  until  a  slight  deposit  of  moisture  appears 
not  only  upon  the  edges,  but  also  upon  the  middle,  and  then  it  is  set 
aside  for  about  ten  minutes. 

The  manipulation  is  continued  by  washing  the  glass  cover  in  water 
and  then  for  a  few  seconds  dipping  it  in  a  mixture  of  one  part  of 
nitric  acid  and  two  of  water  (without  letting  go  of  it  with  the  pincers) 
until  it,  being  again  washed  in  water,  continues  to  show  a  slight 
red  shimmer.  Then  the  preparation  may  be  immediately  examined 
in  Avater :  the  tubercle  bacilli  are  colored  an  intense  red,  while  all 
the  rest  is  colored  a  pale  reddish  tone.  It  is  advisable  to  stain  the 
glass  cover  a  second  time  with  a  watery  solution  of  methylene-blue, 
which  is  done  by  placing  it  in  this  solution  for  a  minute  or  two  after 
taking  it  out  of  the  acid  mixture  and  thoroughly  washing  it  with 
water,  then  again  washing  it,  when  it  may  be  examined. 

Instead  of  fuchsine  and  methylene  blue  we  may,  in  exactly  the 
same  way,  employ  gentian-violet  and  Bismarck-brown.  The  pre- 
parations are  preserved  by  first  drying  them  in  the  air,  then  passing 
them  three  times  through  the  flame  before  laying  them  upon  slides 
upon  which  has  been  placed  a  drop  of  xylol-Canada  balsam. 

The  decolorizing  with  the  nitric  acid  solution  must  not  be  too  pro- 
longed, else  the  bacilli  lose  their  coloring.  With  preparations  that 
are  to  be  preserved,  the  nitric  acid  must  be  very  carefully  removed 
by  repeated  washings  with  water,  because  the  acid  destroys  the  color. 

The  alcoholic  gentian-violet,  as  well  as  the  fuchsine  solution,  retains 
its  color  very  well  Sometimes  the  Bismarck-brown,  and  also  tlie 
methylene-blue,  must  be  filtered  before  using.  Besides  these,  one 
needs  for  his  work  a  black  plate,  two  needles,  a  pincette  with  broad 
beak,  some  watch-glasses,  glass  slides  and  covers,  and  a  spirit-lamp. 

Biedert  has  recently  recommended  the  following  method  for 
demonstrating  the  bacilli  when  they  are  scant  in  numbers :  A  tea- 
spoonful  of  sputum  and  two  teaspoonfuls  of  water  are  boiled  with 
fifteen  drops  of  solution  of  caustic  soda,  then  four  teaspoonfuls  more  of 
water  are  added  and  the  whole  again  boiled  till  it  forms  a  homogeneous 
fluid.  It  is  allowed  to  stand  for  two  days  (not  longer)  in  a  conical 
glass;  possible  bacilli  (and  elastic  fibres)  form  a  sediment.  The  sedi- 
ment  is  stained,  not  by  the  method  described  above,  but  by   the 


EXAMINATION  OF  THE  RESPIRATORV  APPARATUS.        Igy 

method  recommended  by  Ziehl-Neelsen  :  instead  of  the  aniline  water 
and  gentian-violet,  we  use  a  mixture  of  90  parts  of  a  5-per-cent. 
solution  of  carbolic  acid  and  10  parts  of  concentrated  alcoholic  solu- 
tion of  fuchsine,  staining  by  heat  as  above  described ;  the  other  pro- 
cedures are  also  the  same  as  above  referred  to. 

Where  one  is  not  accustomed  to  examine  for  bacillus  tuberculosis, 
for  the  purpose  of  controlling  the  degree  of  staining  he  should  at  the 
same  time  stain  some  sputum  that  is  known  to  contain  the  bacillus 
[or  he  should  keep  test  slides  on  hand]. 

II.  A  now  and  decidedly  useful  mode  of  procedure  is  given  by 
Gabett.  A  dry  preparation  which  has  been  passed  through  a  flame 
is  placed  for  two  minutes  in  a  solution  of  1  part  of  fuchsine  S.  in  100 
parts  of  a  5  per  cent,  solution  of  carbolic  acid  and  10  parts  of  abso- 
lute alcohol,  and  then,  immediately  after,  for  one  minute  in  a  solution 
of  two  parts  of  methylene-blue  to  100  parts  of  25-per-cent.  sulphuric 
acid.  It  is  rinsed  with  water,  and  then,  for  preservation,  is  washed 
with  alcohol,  dried,  and  mounted  in  Canada  balsam.  For  the  sake  of 
greater  certainty,  it  may  be  warmed  in  the  first  solution.  The 
preparations  are  very  beautiful  and  permanent.  The  method  seems 
to  be  a  very  distinct  one.  It  is  necessary  to  make  very  thin,  and 
likewise  uniformly  thin,  preparations. 

The  tubercle  bacilli  are  distinctly  recognized  by  their  red  (or  blue) 
staining.  Since  the  spores  that  may  be  present  are  not  stained,  they 
may  be  seen  in  the  interior  of  bacilli  as  clear  points,  and  they  may  be 
so  abundant  as  to  cause  the  bacilli,  when  only  slightly  magnified,  to 
look  like  the  chain  coccus  (Fig.  40). 

The  presence  of  this  bacillus  in  the  sputum  indicates  tuberculosis 
of  the  lungs  (unless  there  may  be  tuberculosis  of  the  larynx).  Quite 
a  close  approximation  of  the  severity  of  the  disease  may  be  made  by 
the  number  of  bacilli,  but  more  closely  by  the  quantity  of  the 
spores.  Bacilli  may  often  be  discovered  when  the  physical  signs  are 
still  indistinct  or  are  altogether  wanting. 

Absence  of  the  bacilli  at  a  single  examination  is  without  value.  So, 
also,  when  the  sputum  is  scanty  and  not  very  purulent,  if  they  are 
absent  in  repeated  examinations  this  fact  is  to  be  considered  with 
greater  caution.  On  the  other  hand,  in  sputum  that  is  not  too 
scantily  purulent,  the  constant  failure  to  find  bacilli  points  with 
greater  probability  against  tuberculosis.     It  is  to  be  understood  that 


188  SPECIAL  DIAGNOSIS. 

the  staining  material  is  as  it  should  be  (see  above),  that  the  staining 
has  been  properly  done,  and  that  the  most  careful  examination  of  the 
preparation  has  been  made.  The  culture-test,  with  the  material  in 
question,  would  come  still  nearer  the  truth.  (See  also  in  Appendix.) 
Pneumonia  cocci :  The  reports  regarding  these  cocci  are  still  con- 
flicting. Friedliinder  has  found  micrococci  both  in  the  sputum  and  in 
the  tissue-fluid,  of  oval  form,  single,  or  two  or  three  arranged  together, 
lying  in  a  capsule  which  can  be  stained.  But  Friedlander  himself 
acknowledges  that,  without  the  existence  of  pneumonia,  these  cocci — 
or  cocci  which  cannot  be  microscopically  distinguished  from  them — 
are  also  found  in  the  sputum.     We  have  found  Friedlander's  cocci^ 

Fig.  41. 


Frankel's  pneumonia  coccus,  bred  from  the  expectoration.    Prepared  by  Prof.  Gartner. 
Oil  immersion  lens,  one-twelfth;  eye-piece  No.  4. 

in  numerous  cases  of  broncho-pneumonia  and  bronchitis.  The  cocci 
which  A.  Frankel  found  in  the  lungs  in  pneumonia  are  lancet-shaped 
and  thjey  generally  occur  as  double  cocci,  and  are,  like  Friedlander's, 
in  a  capsule.  Frankel's  coccus  is  likewise  found  in  empyema  and 
meningitis,  which  complicate  croupous  pneumonia.  It  also  occurs  in 
normal  saliva.  Finally,  Pio  Foa  has  discovered  in  the  tissue-juice  of 
the  pneumonic  lung  a  diplococcus  inclosed  in  a  capsule  which  is  very 
like  both  of  the  cocci  named  above. 

Staining  of  Friedlander's  coccus  :  A  dry  covering-glass  preparation 
is  placed  for  a  few  minutes  in  a  1-per-cent.  solution  of  acetic  acid, 
then  this  is  blown  away  with  a  pipette ;  dry  in  the  air ;  dip  for  a  few 
seconds  in  aniline  water  and  gentian-violet  solution  (see  above),  rinse 
in  water  (Friedlander.)  Frankel's  coccus  is  stained  with  all  aniline 
dyes.     Pio  FoA  recommends  Gram's  method  for  his  coccus. 

3.  Micrococci i2ii\di  bacilli  of  all  sorts,  also  spirochcefce,  are  found 
[1  Friedlander's  cocci  are  now  known  to  be  bacilli.] 


EXAMINATION  OF  THE  RESPIRATORY  APPARATUS. 


189 


in  every  specimen  of  sputum — from  the  mouth  !  They  are  very 
much  increased  in  fetid  bro7ichitis,  in  bronchiectatic  cavities  and 
gangrene  of  the  lungs;  and  also  in  every  sputum  that  has  stood 
long  and  become  foul. 

Fig.  42. 


Micrococci,  bacilli,  spirals,  spirochjetae,  from  the  sputum.     (After  PFLUEGaE.) 

There  may  be  a  simple  staining  of  the  dry  preparation  with 
methylene-blue,  after  which  it  is  to  be  rinsed  in  water.  Or,  the  prepa- 
ration, stained  according  to  Gram,  with  gentian-violet  solution  and 
aniline  water  (see  p.  187),  may  be  taken  from  this  and  immersed  for 


Fig.  43. 


^ 

Actinomyces.     (After  v.  Jaksch.) 

two  or  three  minutes  in  the  following  preparation :  Iodine,  1,  potass, 
iod.,  2,  aq.  destil.,  300;  then  in  absolute  alcohol  till  the  color  disap- 
pears.   Only  the  microbes  are  stained,  but  these  are  intensely  colored. 

4.  Actinomyces.  In  actinomycosis  of  the  lungs  or  of  the  pleura, 
in  isolated  cases,  this  fungus  is  found  in  the  sputum.  I  have  observed 
it  in  the  characteristic  small  kernels  (see  p.  175).  It  is  recog- 
nized by  the  projections,  like  clubs,  closely  pressed  together,  which 
project  from  the  surface  of  a  confused  mass,  which  look  much 
like  detritus.      We  can  best  see  the  club-like  projections   without 


190  SPECIAL  DIAGNOSIS. 

staining.  The  fungus  can  be  distinctly  stained  by  Gram's  method 
[described  on  the  preceding  page]. 

Mould  (aspergillus,  mucor)  and  isolated  yeast-cells,  when  seen  in 
the  sputum  are  without  significance.  The  microbe  of  whooping-cough 
of  Letzerich  and  Berger  still  needs  confirmation. 

Chemical  Examination. — This  has  a  minor  place,  considered 
with  reference  to  diagnosis. 

There  occur  in  the  sputum  albuminous  corpuscles  in  the  form  of 
mucin,  nuclein,  serum-albumin.  The  latter  is  very  abundant  in 
oedema  of  the  lungs.  Peptone  is  found  very  abundantly  in  the 
sputum  after  the  crisis  of  pneumonia  (Kosselt) ;  it  is  also  found  in 
excess  in  all  purulent  sputum.  Temporary  fatty  acids  occur  very 
abundantly  in  gangrene  of  the  lungs  (Hoppe-Seyler,  Leyden,  and 
Jaff6). 

Finally,  it  is  notable  that  in  gangrene  of  the  lungs  and  bronchitis 
there  is  found  a  ferment  like  the  pancreas  ferment  (Filehne,  Stol- 
nikow). 


CHAPTER    Y. 

EXAMINATION  OF  THE  CIRCULATORY  APPARATUS. 

EXAMIJSTATION    OF    THE    HeART. 

The  development  of  the  methods  of  local  examination  of  the  heart 
is  closely  connected  with  the  introduction  of  percussion  and  ausculta- 
tion. So  v:e  have  here  also  chiefly  to  thank  Laennec  and  Skoda,  as 
well  as  PJorry,  Friedreich,  Bamber  and  Gerhardt. 

ANATOMY  OF  THE  NORMAL  HEART. 

The  heart  lies  upon  the  diaphragm,  sloping  obliquely  forward  in 
such  a  way  that  its  long  axis  is  inclined  forward  and  toward  the  left. 
It  extends  from  about  8  or  9  centimetres  to  the  left  of  the  median 
line  (apex  of  the  heart),  to  about  4  or  5  centimetres  to  the  right  of 
the  same  (^.  e.,  about  one  and  a  half  finger-breadths  to  the  right  of 
the  right  border  of  the  sternum — right  auricle),  so  that  about  two- 
thirds  of  the  heart  is  in  the  left  half  of  the  chest,  and  one-third  in  the 
right  half  Its  highest  point  (the  left  auricle)  is  at  the  lower  border 
of  the  sternal  insertion  of  the  second  rib,  its  lowest  point  at  the  upper 
border  of  the  sixth  costal  cartilage,  or  the  fifth  intercostal  space  (see 
Fig.  44).  The  three  borders  of  the  heart  are  formed  as  follows:  the 
right  by  the  right  auricle,  the  lower  by  the  right  ventricle,  and  the 
left  by  the  left  ventricle.  Only  a  small  portion  of  the  latter  lies  on 
the  anterior  surface,  much  the  greater  part  of  which  is  formed  by 
the  right  ventricle. 

The  figure  (Fig.  44)  shows  how  the  lungs  glide  over  the  heart,  so 
that  only  a  small  four-cornered  portion,  belonging  exclusively  to  the 
right  ventricle,  is  in  contact  with  the  wall  of  the  chest.  Of  the  bor- 
ders of  this  superficial  part  of  the  heart,  the  one  toward  the  right  lies 
between  the  middle  line  and  the  left  sternal  line,  the  upper  behind 
the  fourth  rib,  the  left  somewhat  outside  of  the  left  parasternal  line. 
Below,  the  heart  is  in  relation  with  the  liver  in  such  a  way  that  it 

(191) 


192 


SPECIAL  DIAGNOSIS. 


overlaps  the  latter  witli  its  lower  border.  It  can  be  seen  from  the 
course  of  the  line  c  d,  which  indicates  the  complementary  space  of 
the  incisura  cardiaca  lob.  sup.  sinistra,  what  a  considerable  portion 
of  the  heart  which  is  in  contact  with  the  chest- wall  would  became  still 
smaller  if  the  lung  should  completely  fill  the  complementary  space. 


Fig.  44. 


•"5^  TO 

Position  of  the  contents  of  the  thorax,  of  the  stomach,  and  of  the  liver  from  in  front. 
CWeil-Luschka.)  The  portions  of  the  heart  and  liver  which  are  drawn  with  unbroken 
hatched  lines  represent  the  extent  to  which  these  organs  are  in  contact  with  the  chest- 
wall.  The  portions  that  are  not  in  contact  with  the  chest- wall,  but  are  covered  by  the 
lungs,  are  represented  by  broken  (clear)  hatched  lines,  ef,  border  of  the  right  lung, 
^f  A,  border  of  the  left  lung;  a  6  and  c  c?  (.  .  .  .),  the  boundaries  of  the  complementary 
pleural  sinus,  t,  boundary  between  the  upper  and  middle  lobes  of  the  right  lung;  /:. 
boundary  between  the  middle  and  lower  lobe  of  the  right  lung;  1,  boundary  between 
the  upper  and  lower  lobe  of  the  left  lung,     w,  stomach  (greater  curvature). 


These  are  the  location  and  extent  as  they  are  found  in  the  adult  in 
the  dorsal  or  upright  position.  With  children  the  heart  (as  well  as  the 
diaphragm  and  the  lower  borders  of  the  lungs)  is  about  one  rib  higher. 
It  is  also,  since  it  is  proportionately  larger,  to  a  larger  extent  in  con- 
tact with  the  wall  of  the  chest ;  with  increasing  age,  on  the  other 
hand,  it  moves  lower  down  (to  the  lower  border  of  the  sixth  rib  (the 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.        193 

sixth  intercostal  space)  with  a  smaller  portion  parietal,  since  the  lungs 
lie  over  it  to  a  larger  extent.  In  the  side  position,  especially  on  the 
left  side,  the  heart  always  sinks  very  considerably  to  the  lower  side. 
(See  under  Apex-beat.) 

Situs  viscerum  inversus  exhibits  the  heart  in  such  a  way  that 
"right"  and  "left"  are  exactly  reversed,  like  the  reflection  in  a 
mirror.     Hence  we  need  not  say  anything  more  about  it. 

Preliminary  Remarks  necessary  to  Understand  the  Physical 
Phenomena  of  the  Heart. 

What  follows  is  a  brief  explanation  of  those  facts  regarding  the 
physiology  and  the  general  pathology  of  the  heart,  which  must  be 
always  kept  in  mind  by  the  educated  physician  in  examining  and 
forming  a  judgment  of  the  heart. 

1.  The  movement  of  the  Mood  in  the  heart.  The  blood  flows  from 
the  body  through  the  cavce  into  the  right  auricle,  from  whence,  during 
the  ventricular  diastole,  it  passes  through  the  right  auriculo-ven- 
tricular  opening,  the  tricuspid  valve,  into  the  right  ventricle,  being 
urged  forward  toward  the  end  of  the  diastole  by  the  weak  muscular 
contraction  of  the  right  auricle.  The  systole  which  immediately  fol- 
lows drives  the  blood  out  of  the  ventricle,  the  tricuspid  valve  being  at 
the  same  time  closed,  through  the  open  pulmonary  semilunar  valve 
into  the  pulmonary  artery.  The  blood,  prevented  from  flowing  back 
into  the  ventricle  during  the  diastole  which  immediately  follows  by 
the  closure  of  the  pulmonary  semilunar  valve,  passes  -through  the 
lungs,  and  from  them  flows  into  the  left  auricle,  whence,  by  the  dias- 
tole of  the  ventricle,  it  flows  through  the  left  auriculo-ventricular 
opening,  the  mitral  valve,  into  the  left  ventricle,  whither  it  is  again 
assisted  at  the  end  of  the  diastole  by  the  contraction  of  the  auricle. 
The  left  ventricle  discharges  its  contents  during  the  systole  (the  mitral 
valve  being  closed)  into  the  commencement  of  the  aorta,  through  the 
open  aortic-semilunar  valve,  whence  it  is  prevented  from  returning  to 
the  ventricle  when  the  pressure  from  the  ventricle  ceases  and  the 
diastole  begins,  by  the  closure  of  the  aortic  semilunar  valve.  The 
blood  then  flows  from  the  conus  aortce  into  the  body. 

2.  Valvular  insufficiency  and  its  effects  upon  the  movement  of  the 
blood.     From  the  foregoing  it  is  evident  that  the  openings  of  the 

13 


194  SPECIAL  DIAGNOSIS. 

heart  are  very  important  factors,  on  the  one  side  being  the  entrance 
and  exit  of  the  ventricles,  and  on  the  other  being  the  location  of  the 
valves  of  the  heart  which  hinder  any  backward  flow  of  the  blood. 
The  motion  of  the  blood  can  only  in  two  ways  be  interfered  with  by 
pathological  processes  at  the  openings  of  the  heart :  either  by  nar- 
rowing at  the  opening  [stenosis  of  valve),  or  by  the  valves  losing  their 
power  to  close  {insufficiency  of  the  particular  valve). 

Stenosis  of  a  valve  may  be  caused  by  products  of  endocarditis, 
which  cause  adhesion  of  the  flaps  of  the  valve,  with  formation  of  a 
cicatricial  narrowing  ring  at  the  base  of  the  valves.  Insufiiciency 
may  likewise  be  caused  by  endocarditis  (general  shortening  of  the 
flaps  and  of  the  tendinous  processes  of  the  papillary  muscles),  and 
this  is  the  most  frequent  cause  of  insufficiency ;  but  the  condition 
may  also  arise  from  a  distention  of  the  opening  so  that  the  flaps  are 
too  short  to  close  it  (relative  valvular  insufficiency,  in  weak  heart 
with  dilatation). 

An  opening  that  is  narrowed  hinders  the  passage  of  the  blood 
through  it.  If  it  is  an  auriculo-ventricular  opening  {mitral  or  tri- 
cuspid stenosis),  then,  at  the  moment  of  diastole  of  the  heart,  the  blood 
is  hindered  in  its  entrance  into  the  ventricles :  there  is  imperfect 
filling  of  the  ventricles ;  if  it  is  an  arterial  opening  that  is  narrowed 
[aortic  or  pulmonary  stenosis),  then  the  exit  of  the  blood  from  the 
ventricles  at  the  systole  is  interfered  with.  If  the  valvular  mechanism 
is  in  such  a  condition  that  it  cannot  perfectly  close,  then  at  the 
moment  when  it  ought  to  close  it  allows  a  part  of  the  blood  to  flow 
backward.  If  the  difficulty  is  with  the  entrance  to  the  ventricles 
(insufficiency  of  mitral  or  tricuspid  valve),  then  with  the  systole  a 
part  of  the  contents  of  the  ventricle  flows  back  into  the  auricle ;  but 
if  the  deficiency  is  at  the  outlet  of  the  ventricle  {insufficiejicy  of  the 
aortic  or  pulmonary  valve),  then  at  the  end  of  the  systole,  during  the 
diastole  which  follows,  a  part  of  the  blood  that  has  just  been  thrown 
into  the  artery  will  be  thrown  back  into  the  ventricle. 

In  one  respect  all  the  defects  that  have  been  mentioned  are  alike : 
they  check  the  blood  current,  they  cause  a  stasis  of  blood  in  that 
chamber  of  the  heart  which  is,  with  reference  to  the  direction  of  the 
blood  current,  just  behind  the  defective  opening.  Thus  a  defect  of  an 
arterial  opening  causes  stasis  in  the  corresponding  ventricle ;    a  defect 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.        I95 

in  an  auriculo-ventricular  opening  occasions  stasis  in  the  corresponding 
auricle,  and  also  beyond  this  in  the  corresponding  veins. 

3.  Compensation,  accommodation  of  valvular  deficiency.  The 
abnormal  resistance  which  is  exerted  against  the  blood-current  from 
the  valvular  defect  would  immediately  lead  to  more  considerable  dis- 
turbances of  the  blood-current  if  it  were  not  promptly  equalized  by  the 
increased  work  of  that  section  of  the  heart  lying  (in  the  course  of  the 
blood-current)  above  the  point  of  resistance.  But  this  does  not  con- 
tinue, for  with  increased  work  the  overloaded  section  of  the  heart 
becomes  hypertrophied — compensatory  hypertrophy.  This  condition 
is  extremely  simple  in  defects  at  the  aortic  opening.  They  are  com- 
pensated by  hypertrophy  of  the  left  ventricle,  which  is  associated  with 
dilatation  (eccentric  dilatation).  The  latter  is  especially  irarked  in 
insufficiency  of  the  aortic  valve,  and  this  is  explained  by  the  fact  that, 
with  aortic  insufficiency,  the  left  ventricle  during  the  diastole  receives 
blood  from  two  sources,  hence  very  much  more  than  normal.  With 
mitral  insufficiency  the  auricle  must  accommodate  for  the  defect;  but, 
notwithstanding  the  fact  that  it  becomes  dilated  and  hypertrophied,  it 
cannot  perform  the  necessary  work,  cannot  overcome  the  stagnation  : 
the  accumulated  blood  passes  through  it  to  the  veins  of  the  lungs, 
capillaries  and  arteries  of  the  lungs,  and  so  on  till  it  reaches  the  right 
ventricle;  this  becomes  dilated  and  hypertrophied,  and  thus  causes  the 
increase  of  the  propulsive  power  necessary  for  the  accommodation. 

Though  defect  of  the  valve  of  the  pulmonary  artery  is  rare,  the 
actual  consequences  are  the  same  as  of  defect  of  the  aortic  valve, 
defect  of  the  tricuspid,  which  is  likewise  rare,  with  the  exception  of 
relative  insufficiency,  and  produces  accommodation  of  hypertrophy  of 
the  right  auricle,  but  only  to  a  very  slight  degree ;  for  the  increased 
pressure  in  the  general  venous  system  has  no  effect  upon  the  pressure 
in  the  arteries  of  the  body,  and  hence  cannot  produce  any  notable 
compensatory  hypertrophy  of  the  left  ventricle. 

Thus,  insufficiency  and  stenosis  of  the  aorta  cause  hypertrophy  of 
the  left,  and  insufficiency  and  stenosis  of  the  mitral  valve  hypertrophy 
of  the  right,  ventricle.  But  with  mitral  insufficiency  something  more 
follows :  during  the  diastole  of  the  left  ventricle  there  flows  into  it 
from  the  dilated  auricle  the  blood  which  has  accumulated  there  under 
very  much  increased  pressure  and  in  increased  quantity  ;  it  becomes 
dilated,  and,  since  it  also  has  to  dispose  of  the  increased  quantity  of 


196  SPECIAL  DIAGNOSIS. 

blood,  which  it  does  by  driving  part  of  it  forward  into  the  aorta  and 
part  backward  through  the  mitral  orifice  into  the  auricle,  it  also 
becomes  hypertrophied.  Hence  mitral  insufficiency  leads  to  hyper- 
trophy and  dilatation  of  both  ventricles. 

These  different  hypertrophies  are  aids  in  the  diagnosis  of  the  indi- 
vidual valvular  lesions. 

4.  Hypertrophy  of  the  heart  from  other  causes.  Besides  the  val- 
vular defects,  certain  other  conditions  lead  to  hypertrophy :  thus,  the 
left  ventricle  becomes  hypertrophied  by  the  increased  resistance  in 
the  general  arterial  system  produced  by  sclerosis  of  the  arteries ;  it 
sometimes  results  from  continued  excessive  muscular  exertion  [idio- 
pathic hypertrophy),  further,  from  different  forms  of  chronic  nephritis, 
and  in  this  it  is  more  marked  the  longer  the  general  vigor  is  main- 
tained (hence  most  marked  in  renal  atrophy) ;  finally,  also  in 
acute  nephritis,  if  it  lasts  long  enough.  The  right  ventricle  becomes 
hypertrophied  whenever  there  is  continued  increased  resistance  in  the 
pulmonary  circulation,  most  regularly  and  markedly  in  emphysema 
(from  destruction  of  the  capillaries  of  the  lungs  from  atrophy  of  the 
tissue),  in  marked  contraction  of  the  lungs,  in  marked  kyphoscoliosis. 

5.  The  form  of  the  heart  is  changed  in  consequence  of  the  hyper-" 
trophy  (and  dilatation) ;  hypertrophy  of  the  left  ventricle  broadens 
the  heart  to  the  left  and  somewhat  lengthens  it ;  if  there  is  dilatation 
also,  the  broadening  to  the  left  is  still  more  increased.  Hypertrophy 
and  dilatation  to  the  right  ventricle  simply  broaden  the  heart  to  the 
right.  Hypertrophy  and  dilatation  of  both  ventricles  broaden  the 
heart  in  both  directions  and  lengthen  it. 

6.  Simple  dilatation.  This  results  entirely  from  weakness  or 
paralysis,  and  is  dependent  upon  a  diminished  tone  of  the  heart-muscle 
with  a  simultaneous  loss  of  its  power  to  contract.  It  may  also  occur 
in  a  heart  that  was  previously  dilated  and  hypertrophied,  and  it  then 
results  in  a  very  great  enlargement  of  the  heart.  In  dilatation  of  the 
heart  the  enlargement  is  nearly  symmetrical  in  all  directions. 

The  diagnosis  between  enlargement  of  the  heart  from  hypertrophy 
(with  dilatation)  and  the  dilatation  just  mentioned  is  chiefly  made  by 
the  consideration  of  the  evidences  of  the  amount  of  work  the  heart  is 
doing. 

7.  The  extent  to  which  the  heart  is  in  contact  with  the  chest-wall 
is  in  very  close  relation  to  the  size  of  the  heart  (regarding  the  peri- 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.        197 

cardium,  see  later).  An  enlarged  heart  always  has  a  larger  area  in 
contact  with  the  chest-wall  than  does  a  normal  heart,  if  there  are  no 
conditions  in  the  neighborhood  of  the  heart  which  keep  it  away  from 
the  chest-wall.  This  may  be  occasioned  by  emphysema  of  the  lungs, 
or  by  an  increase  in  the  volume  of  the  lungs,  whether  from  anomaly 
of  both  lungs  or  only  of  the  left  lung,  either  chronic  or  temporary. 
In  emphysema  a  normal  heart  therefore  would  be  to  a  less  extent 
parietal  than  if  the  lungs  were  normal ;  hence  in  case  of  emphysema 
an  enlarged  heart  may  possibly  not  be  manifest  by  its  size,  as  it  would 
be  if  the  lungs  were  normal.  When  there  are  both  enlargement  of 
the  heart  and  emphysema  of  the  lungs  the  heart  may  be  found  to  be 
parietal  only  to  the  normal  extent,  or  may  be  so  to  an  even  less  extent 
than  normal  (overlying  of  the  heart). 

Still  another  condition  has  its  effect :  inflammatory  adhesion  of  the 
border  of  the  lungs  at  the  incisura  cardiaca  with  the  parietal  pleura. 
This  unchangeably  determines  the  parietal  relation  of  the  heart.  And 
yet,  often  in  this  condition,  just  the  opposite  takes  place,  as  in  the  pre- 
vious case ;  from  shrinking,  the  lung  is  somewhat  drawn  away  from 
the  heart  and  thus  it  is  more  largely  parietal  than,  according  to  its 
size,  it  would  be.     Enlargement  of  the  heart  may  thus  be  simulated. 

Hence  in  forming  an  opinion  as  to  the  size  of  the  heart  from  the 
extent  to  which  it  is  in  contact  with  the  chest-wall  we  must  always 
bear  in  mind  the  possibility  of  the  presence  of  these  conditions  (see 
Percussion  ;  "  absolute  heart  dulness  "). 

INSPECTION    AND    PALPATION    OF    THE    REGION    OF    THE    HEART, ^ 

.  Both  these  methods  of  examining  the  heart,  like  the  foregoing,  will 
be  best  practised  in  a  moderately  high  dorsal  position.  There  are 
technical  difficulties  in  examining  a  patient  either  standing  or  sitting; 
but  sometimes  in  severe  heart  diseases  the  latter  cannot  be  avoided  on 
account  of  the  existence  of  orthopncea  (see  pp.  32,  97).  Palpation  may 
be  performed  either  with  the  tips  of  the  first  and  second  fingers,  or 
with  the  flat,  bare  hand. 

The  Apex-heat. 

Normal  conditions.  The  apex-beat  is  of  the  greatest  importance 
as  an  anatomical  starting-point,  for  it  corresponds  either  exactly  to 

1  The  two  methods  of  examination  have  such  close  connection  with  reference  to  the 
heart  that  to  separate  them  would  seem  to  be  artificial. 


198  SPECIAL  DIAGNOSIS. 

the  apex  or  to  a  spot  very  close  to  it,  a  little  nearer  to  the  median 
line.  In  the  majority  of  healthy  persons  it  is  recognizable,  by  the 
eye,  as  well  as  by  the  finger  applied  to  the  spot,  as  a  rhythmical 
and  systolic  projection  forward  about  the  breadth  of  the  finger,  which 
in  the  adult  in  the  upright  or  dorsal  position  occurs  in  the  fifth 
intercostal  space  just  within  the  mammillary  line;  only  exceptionally, 
chiefly  with  persons  with  very  short  chest,  it  is  found  in  the  fourth 
intercostal  space.  In  children,  up  to  the  age  of  ten  years,  it  is 
usually  found  in  the  fourth  intercostal  space  and  either  in  the 
mammillary  line  or  just  outside  of  it  (see  above  in  the  section  on 
Anatomy).  In  old  age,  on  the  contrary,  it  is  sometimes  found  in 
the  sixth  intercostal  space.  Much  fat,  or  the  mamma,  also  narrow 
intercostal  spaces,  render  it  invisible,  but  yet  it  may  generally  be  felt. 
Moreover,  without  a  distinct  cause,  it  may  sometimes  be  entirely 
wanting  in  healthy  persons. 

Quiet  breathing  produces  no  change  in  the  apex-beat.  With  deep 
inspiration,  it  is  covered  by  the  distended  lung,  which  then  occupies 
the  complementary  space  ;  if  it  be  still  evident,  it  moves  sometimes  an 
intercostal  space  lower  down,  corresponding  to  the  inspiratory  sinking 
of  the  diaphragm. 

The  effect  of  change  of  posture  is  very  noticeable  in  the  side  posi- 
tion :  the  left-side  position  moves  the  apex-beat  outward  beyond  the 
mammillary  line,  even  as  far  as  the  anterior  axillary  line ;  the  right- 
side  position  causes  the  beat  to  disappear  or  moves  it  somewhat  to  the 
right. 

Physical  exertion  and  mental  excitement,  the  chief  physiological 
disturbers  of  the  heart's  action,  may  noticeably  change  the  apex-beat 
in  perfectly  sound  persons,  but  still  more  in  nervous  persons :  it  may 
become  plainly  stronger  and  even  broader,  or  move  somewhat  to  the 
left. 

There  is  much  dispute  as  to  the  cause  of  the  apex-heat.  It  is 
certain  that  it  is  produced  by  a  variety  of  causes.  Briefly  stated  they 
are  as  follows  : 

1.  Change  in  the  form  of  the  heart  at  the  systole :  its  transverse 
measurement  (antero-posteriorly)  increases  (Ludwig);  the  apex  moves 
forward,  to  the  right,  and  upward  (Filehne,  Penzoldt). 

2.  Change  in  the  location  of  the  heart :  it  revolves  upon  its  long 
axis,  so  that  the  stronger  left  ventricle  moves  toward  the  front. 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.        I99 

The  assumption  that  has  hitherto  been  made  that  the  apex-beat  is 
wholly  or  in  part  to  be  explained  by  the  recoil  (the  so-called  Gutbrod- 
Skoda,  better  Alderson's,  theory),  must  henceforth  be  regarded  as 
abandoned,  since  Martins  has  proved  that,  at  the  time  when  the  apex- 
stroke  takes  place,  the  semilunar  valves  are  not  yet  closed,  and  the 
gush  of  the  blood  into  the  vessels  consequently  does  not  begin  till  the 
apex-stroke  is  over. 

Displacement  {dislocation)  of  the  apex-beat  in  disease.  It  may  be 
brought  about :  (a)  by  dislocation  of  the  heart,  [b)  by  enlargement  of 
the  heart. 

(a)  Dislocation  of  the  heart.  The  apex-beat  is  a  very  important 
sign  for  determining  this,  since  the  other  methods  often  have  a  very 
indefinite  result,  or  may  entirely  fail. 

Deformity  of  the  thorax  may  cause  displacement  in  all  possible 
directions.  It  may  happen  that  in  a  chest  that  is  flattened  or  pressed- 
in  in  the  neighborhood  of  the  heart  the  apex-beat  (likewise  the  heart) 
will  be  found  considerably  outward  or  considerably  inward. 

Emphysema  of  the  lungs,  in  case  the  apex-beat  is  not  lost  by  the 
overlapping,  presses  it  down  into  the  sixth  intercostal  space  (depression 
of  the  diaphragm). 

In  exudative  pleuritis  and  jjneumothorax  the  heart  and  apex-beat 
are  pushed  toward  the  sound  side,  in  the  worst  cases  as  far  to  the  left 
as  the  middle  axillary  line,  but  to  the  right  very  rarely  beyond  the 
mammillary  line.  Likewise,  the  mediastinum  and  the  base  of  the 
heart  move  over,  although  not  so  far  as  the  apex.  Mediastinal 
tumors  may  have  the  same  effect  as  pleuritis  of  the  right  side. 

In  pleurisy  of  the  right  side  the  apex  is  sometimes  pushed  not  only 
to  the  left  but  also  upward  into  the  fourth  intercostal  space.  We  are 
not  certain  why  this  is  so.  It  is  highly  improbable  that  the  left  lobe 
of  the  liver  rises  up  while  the  right  is  dragged  down,  for  the  point  of 
traction,  the  suspensory  ligament,  brings  it  still  lower  by  the  pressure 
of  the  exudation  upon  the  right  side.  The  location  of  the  heart  when 
pressed  upon  is  subject  to  many  disturbances,  which  we  cannot 
describe  at  this  time. 

Shrinking  of  the  lungs  and  of  the  side  of  the  chest  after  a  pleuritis 
draws  the  mediastinum  and  the  heart  into  the  diseased  side,  and  at 
the  same  time  draws  the  diaphragm  up ;  hence  in  shrinking  of  the 
right  side  the  heart  moves  upward  and  to  the  right  side,  but  in  disease 
of  the  left  side  it  is  drawn  upward  or  upward  and  to  the  left. 


200  SPECIAL  DIAGNOSIS. 

If  the  heart  chances  to  be  drawn  to  the  right  so  much  as  to  bring 
it  under  or  close  up  to  the  sternum,  where  the  intercostal  spaces  are 
very  narrow,  of  course  we  cannot  observe  the  apex-beat. 

In  exudative  pleuritis  it  sometimes  happens  that  the  heart  becomes 
fixed  by  inflammatory  adhesions,  and  then  the  apex-beat  remains 
at  that  point  even  after  the  cause  of  the  displacement  has  been 
removed. 

Elevation  of  the  diaphragm  as  a  result  of  peritonitis  or  of  simple 
mechanical  pressure  from  below,  or  from  neurotic  paralysis  of  the 
diaphragm,  causes  dislocation  of  the  heart  upward  or  upward  and  to 
the  left. 

(h)  Enlargement  of  the  heart.  Hypertrophy  and  dilatation  of  the 
left  ventricle  are  made  manifest  by  displacement  of  the  apex-beat 
outward  or  outward  and  downward,  and  under  some  circumstances  as 
far  as  to  the  posterior  axillary  line  and  the  eighth  intercostal  space. 
The  apex-beat  is  also  broader  and  stronger,  see  below. 

The  conditions  which  bring  about  hypertrophy  and  dilatation  of 
the  left  side  have  been  referred  to  on  page  195.  Likewise  hyper- 
trophy and  dilatation  of  the  right  ventricle  displace  the  apex-beat  a 
little  toward  the  left,  since  the  large  right  ventricle  pushes  the  left 
somewhat  to  one  side.  But  the  displacement  is  always  quite  small, 
at  most  not  beyond  the  mammillary  line. 

Alteration  in  the  Width  and  Strength  of  the  Apex-heat. 

We  judge  of  the  breadth  both  by  inspection  and  palpation.  We 
seldom  have  an  increase  in  the  breadth  without  an  increase  in  the 
strength  as  well :  in  the  normal  heart,  if  it  becomes  parietal  over  a 
larger  area  from  shrinking  of  the  lungs ;  moreover,  I  have  sometimes 
seen  it  with  deformity  of  the  chest  (without  hypertrophy  of  the  heart) 
and  where  there  was  marked  wasting,  so  that  the  patient  was  very  lean. 

As  a  rule,  breadth  of  the  apex-beat  is  associated  with  a  strong  beat. 

The  strength  of  the  apex-beat  can  only  be  made  out  by  palpation. 
By  constant  practice  with  the  hand  it  can  be  distinctly  recognized. 
An  apex-beat  that  is  so  strong  that  it  lifts  the  finger  that  is  mod- 
erately pressing  over  it  is  called  "  heaving." 

Temporary,  often  notably  strengthened  and  moderately  broadened 
impulse  is  caused  by  increased  heart- work  (see  above)  in  consequence 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.        201 

of  exertion  and  mental  excitement.  For  this  reason  the  heart  ought 
always  to  be  examined  only  Avhen  these  two  conditions  can  be 
excluded. 

In  nervous  palpitation,  Basedow's  disease,  and  sometimes  in  chronic 
nicotine-poisoning,  the  heart-beat  may  for  a  time  be  very  much 
stronger  and  even  somewhat  broader,  as  an  indication  of  the  increased 
work  of  the  heart,  without  any  organic  change  in  it.  The  same  thing 
occurs,  though  in  a  moderate  degree,  in  fever.  Moreover,  the  apex- 
beat  may  be  stronger  at  the  same  time  that  the  heart's  work  is  not 
increased,  if  the  heart  is  pressed  firmly  against  the  chest-wall,  as  in 
mediastinal  tumors. 

Continued  strength  and  breadth  of  apex-beat  is  the  most  important 
sign  of  hypertrophy  of  the  left  ventricle.  In  well-marked  cases  the 
beat  is  "heaving,"  and  is  as  wide  as  several  fingers — being  displaced 
toward  the  left  and  downward  (see  above). 

It  is  assumed  that  an  enlarged  heart  works  with  strength  increased 
in  proportion  to  its  increased  volume.  If  the  heart  becomes  weak, 
then  there  is  a  diminution  as  regards  the  breadth  and  strength ;  and 
yet  it  may  be  distinctly  recognized  as  diseased. 

In  many  cases  it  is  difficult  to  separate  the  apex-beat  from  the 
"heart-beat"  in  general,  for  which  see  p.  203. 

Weakening  of  the  apex-beat.  It  has  been  mentioned  already  that 
the  apex-beat  may  be  weak  in  persons  who  are  perfectly  healthy,  or 
it  may  be  entirely  wanting. 

Pathologically  it  is  diminished  or  lost : 

By  the  activity  of  the  heart  being  concealed  by  overlapping :  from 
emphysema  of  the  lungs,  by  a  pleuritic  or  pericardial  exudation,  and 
by  tumors. 

By  oedema,  emphysema  of  the  skin,  inflammatory  diseases  of  the 
chest-wall  in  the  neighborhood  of  the  heart. 

By  diminution  of  the  work  of  the  heart,  as  takes  place  with  any 
kind  of  degeneration  of  the  heart-muscle ;  here  we  may  mention  : 
myocarditis,  lipomatosis  cordis,  weakness  or  degeneration  of  an  hyper- 
trophied  heart,  especially  with  incompensation  with  valvular  deficiency, 
weakness  in  febrile  diseases  (especially  collapse). 

The  disappearance  of  an  apex-beat  which  has  previously  been  dis- 
tinct is  sometimes  the  only  sure,  and  hence  is  a  very  important,  sign 
of  the  development  of  exudative  pericarditis.     But  diminution  of  the 


202  SPECIAL  DIAGNOSIS. 

work  of  the  heart  is  more  distinctly  declared  at  the  radial  pulse  than 
by  the  apex-beat ;  see  below  for  the  explanation  of  the  meaning  of  all 
these  conditions.  Moreover,  the  radial  pulse  is  the  only  direct  meas- 
urer of  what  the  heart  does  in  all  the  above-mentioned  cases  of  con- 
cealment of  the  work  of  the  heart.  It  is  especially  important  in 
pericarditis. 

Where  the  apex-beat  is  covered  by  fluid  in  the  pericardium  it  often 
again  becomes  distinct  when  the  patient  sits  up  or  bends  forward, 
because  the  heart  then,  on  account  of  its  greater  weight,  rests  against 
the  chest-wall.  It  is  then  often  found  in  the  sixth  intercostal  space, 
because  the  distended  pericardium  presses  the  diaphragm  down.  This 
sign,  of  course,  is  wanting  in  cases  where  the  apex-beat  is  missed  from 
weakness  of  the  heart. 

Further,  the  apex-beat  is  wanting  where  there  are  pericardial 
adhesions  (see  below  under  Systolic  Retraction),  and  sometimes  in 
stenosis  of  the  commencement  of  the  aorta,  and  this  notwithstanding 
the  existence  of  hypertrophy  of  the  left  ventricle  (slow  ventricular 
contraction  resulting  from  difficulty  in  emptying  itself). 

So  far  as  experience  goes,  '■^systolic  drawing-in''  in  the  neighbor- 
hood of  the  apex-beat  has  no  diagnostic  value.  Regarding  systolic 
drawing-in  of  the  whole  lower  region  of  the  heart,  see  below. 

Doubling  of  the  apex-beat,  so  that  a  single  pulsation  of  the  carotid 
corresponds  to  two  beats  at  the  apex,  occurs  in  hemisystole  (Leyden). 
By  this  we  have  understood  an  action  of  the  heart  in  which  both  ven- 
tricles do  not  contract  exactly  simultaneously,  so  that  then  the  con- 
traction of  the  left  ventricle,  as  well  as  the  right,  causes  an  apex-beat. 
But  it  is  probable  that  we  here  have  in  these  cases  simply  an 
alternating  action  of  the  heart  (see  Pulsus  Alternans),  in  which  the 
contraction  of  the  heart  is  too  feeble  to  produce  a  perceptible  pulse 
every  time. 

The  application  of  the  graphic  method  to  the  apex-beat  (cardi- 
ography) has  thus  far  yielded  no  notable  contribution  to  pathology. 

The  Neighborhood  of  the  Heart  in  general. 

Prominence  of  the  neighborhood  of  the  heart,  including  the  ribs  and 
sternum,  takes  place  gradually  in  marked  hypertrophy  and  dilatation  ; 
when  there  are  hypertrophy  and  dilatation  of  both  ventricles  or  of  the 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.        203 

right  alone  the  swelling  extends  sometimes  beyond  the  sternum  ;  in 
hypertrophy  of  the  left  ventricle  alone  it  lies  more  to  the  left.  Peri- 
carditis exudativa  sometimes  causes  a  distinct  swelling. 

This  sign  depends  upon  two  factors  :  the  size  of  the  heart  or  of  the 
pericardium,  and  the  flexibility  of  the  chest- wall.  If  the  latter  is 
marked  the  swelling  develops  quickly,  as  in  acute  pericarditis,  and  is 
very  marked  (enlargement  of  the  heart  in  children) ;  when  the  thorax 
is  rigid  there  may  be  no  projection,  though  the  heart  is  very  large. 
This  condition  is  not  to  be  confounded  with  the  pressing  forward  of 
the  heart  from  mediastinal  tumors — aneurism.  Generally  when  there 
is  a  hroad  heart-heat  in  the  intercostal  spaces  in  the  neighborhood  of 
the  heart,  and  even  upon  the  ribs  and  sternum,  it  is  from  a  hyper- 
trophy of  the  heart.  But,  also,  when  there  is  contraction  of  the  left 
lung,  with  the  heart  free  from  attachment,  the  motions  of  the  heart 
may  be  seen  as  well  as  felt  over  a  broader  extent  in  the  intercostal 
spaces.  If,  in  such  cases,  the  heart's  action  is  excited,  there  is  the 
impression  of  a  notable  hypertrophy  of  the  heart,  even  when  the  heart 
is  quite  normal  in  size. 

If,  in  a  case  where  the  heart,  from  dilatation  or  retraction  of  the 
lungs,  is  more  extensively  parietal,  weakness  of  the  heart  occurs,  then 
we  not  infrequently  see  a  broader  waving  in  the  intercostal  spaces, 
which,  by  its  evident  lack  of  energy,  is  visibly  in  contrast  with  its 
former  powerful  motions. 

It  is  sometimes  very  dijfficult  to  distinguish  a  broadened  heart-beat 
from  the  ordinary  apex-beat ;  but  generally  it  can  be  distinguished  by 
its  having  peculiar  vigor,  more  than  other  heart  motions. 

Pulsations  at  the  base  of  the  heart  sharply  limited  to  the  second 
intercostal  space  on  the  right  and  left  side  of  the  sternum  come  from 
the  aorta  or  pulmonary  artery.  They  are  rarely  visible;  generally 
they  can  only  be  felt.  If  they  are  systolic  they  may  indicate  aneurism 
of  these  vessels.  More  frequently  we  may  feel  a  diastolic  shock,  but 
especially  upon  the  left  over  the  pulmonary  artery.  If  the  lungs  and 
heart  are  normal  it  cannot  be  felt ;  but  if  the  lungs  are  drawn  back 
from  the  base  of  the  heart  (by  shrinking,  or  by  enlargement  of  the 
heart),  or  if  there  is  thickening,  then  it  may  be  felt,  especially  if  it  is 
simultaneously  strengthened  by  hypertrophy  of  the  right  ventricle.  In 
emphysema  of  the  lungs  there  exists  the  peculiar  condition  that,  al- 
though the  closure  of  the  pulmonary  valve  is  in  a  marked  degree  stronger, 
yet  it  cannot  be  made  out  because  the  inflated  lung  lies  over  it. 


204  SPECIAL  DIAGNOSIS. 

Pulsation  in  the  region  about  the  heart  occurs  in  empyema  lying 
near  the  heart  upon  the  left  side  (empyema  pulsans) ;  farther  in,  aortic 
aneurism  (which  see). 

Although  systolic  drawing-in  at  the  apex  of  the  heart  is  of  no 
significance  (see  above),  yet  systolic  drawing-in  of  several  intercostal 
spaces  in  the  neighborhood  of  the  heart,  but  especially  of  the  ribs  and 
the  lower  part  of  the  sternum,  is  of  diagnostic  value :  it  is  probable 
that  there  is  pericarditis  adhesiva  with  mediastinal  pericarditis, 
accompanied  by  thickening.  But  yet  these  signs  may  be  entirely 
wanting,  although  the  condition  is  present ;  and,  on  the  other  hand, 
they  may  be  observed  in  cases  where  this  condition  does  not  exist. 
The  drawing-in  may  be  caused  by  a  dense  mediastinum  being  adherent 
to  the  spine  and  again  by  pericardial  adhesion  to  the  chest-wall;  its 
contraction — that  is,  its  constantly  becoming  shorter — must  of  necessity 
cause  a  drawing-in  of  the  chest-wall. 

'■'■Buzzing  "  and  friction-sounds  that  may  be  felt  in  the  neighborhood 
of  the  heart  accompany  very  marked  endocardial  or  pericardial  sounds 
(see  under  Auscultation). 

The  Epigastrium. 

In  inspecting  and  palpating  the  heart  this  must  always  be  considered. 
Systolic  trembling,  or  even  systolic  pulsation,  may  be  observed  here  if 
the  heart,  more  particularly  the  right  ventricle,  is  drawn  nearer  the 
abdominal  wall  by  the  depression  of  the  diaphragm,  but  especially  is 
this  the  case  when,  at  the  same  time,  the  right  ventricle  is  hypertrophied 
— emphysema  of  the  lungs. 

This  epigastric  pulsation  must  not  be  confounded  with  that  which 
is  to  be  seen  from  the  abdominal  aorta  when  the  abdomen  is  very 
empty,  and  the  abdominal  wall  very  thin,  whether  the  aorta  pulsates 
normally  strongly  or  not,  or  whether  there  is  an  aneurism  of  the 
abdominal  aorta.  This  pulsation  is,  moreover,  best  transmitted  when 
a  tumor  of  the  lymphatic  glands,  of  the  stomach,  or  a  thin  but  firm 
liver,  lies  over  the  aorta.  Sometimes  (not  always)  the  pulse  is  felt 
noticeably  later  than  the  systole  of  the  heart. 

Percussion  of  the  Heakt. 

This  has  for  its  object  the  determination  : 

1.   Of  the  absolute,   "small"  dulness  of  the  heart,  which  corre- 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.        205 

sponds  with  the  portion  of  the  heart  that  is  in  contact  Avith  the  chest- 
wall  ;  and  which  has  an  almost  definite  relation  to  the  size  of  the 
heart. 

2.  The  so-called  relative  heart-dulness,  which  lies  above  and  to  the 
left  of  the  absolute  dulness,  and  which  is  determined  by  the  thinness 
of  the  lungs  around  its  border  (see  above,  page  124).  It  often  stands 
indirectly  in  some  relation  to  the  size  of  the  heart,  but  it  is  not  appli- 
cable for  ascertaining  it.  It  does  not  even  show  the  exact  size  of  the 
heart.  . 

To  these  two,  Ebstein  has  added  : 

3.  Palpatory  percussion  of  the  "  heart's  resistance,''  which  is  deter- 
mined by  ascertaining  the  anatomical  size  of  the  heart ;  regarding 
this  method  see  below. 

METHODS  OF  PERCUSSION. 

Normal  Percussion  Figure  of  the  Heart. 

1.  Absolute  heart-dulness.  This  is  determined  by  light  per- 
cussion, and  corresponds,  in  fact,  to  the  portion  of  the  heart  that 
is  parietal.  In  two  respects  it  departs  from  this,  though  not  essen- 
tially ;  the  small  strip  of  the  heart  which  is  parietal  behind  the 
sternum  between  its  left  border  and  the  inner  border  of  the  right 
lung,  is  not  dull  as  would  be  expected,  but  gives  a  clear  sound,  as 
indeed  occurs  over  the  whole  surface  of  the  sternum  (see  above, 
page  123);  the  lingula,  being  so  small,  does  not  aifect  percussion; 
over  it  we  notice  absolutely  deadened  sound.  Thus  we  have  the 
following  figure  of  the  absolute  heart-dulness  in  persons  in  middle 
life  (Fig.  45) :  the  boundary  on  the  right  is  the  left  sternal  line,  the 
upper  boundary  lies  upon  the  fourth  rib,  the  left  boundary  is  outside 
of  the  left  parasternal  line.  The  lower  boundary  toward  the  liver 
cannot  be  exactly  determined,  it  being  defined  by  the  apex-beat, 
and  generally  also  by  the  upper  border  of  the  sixth  rib.  In  chil- 
dren the  area  of  heart-dulness  (absolute)  is  somewhat  greater,  the 
heart  being  relatively  larger,  the  upper  boundary  in  the  third  inter- 
costal space ;  hence  the  apex-beat  is  generally  in  the  fourth  inter- 
costal space,  the  left  boundary  near  the  mammillary  line ;  in  old 
age,  however,  it  is  smaller  (from  inflation  of  the  lungs),  about  over 
the  fifth  rib,  or  the  parasternal  line. 


206 


SPECIAL  DIAGNOSIS. 


In  quiet  breathing  the  dulness  does  not  distinctly  change ;  in  deep 
inspiration  it  is  very  decidedly  diminished,  or  entirely  disappears, 
because  the  costal  cartilages  come  close  together  at  the  sternum. 
Compare  the  course  of  the  boundary  of  the  complementary  space 
(Fig.  44).  It  makes  no  difference  whether  the  examination  is  made 
in  the  dorsal  or  the  upright  position.  Examination  upon  the  side 
makes  considerable  alteration  of  the  area  of  dulness. 


Fig.  45. 


Percussion  boundary  of  the  lung;s  in  front  (Weil),  g  h.  The  upper  limits  of  the  lungs ; 
■ef,  the  lower  limits  of  the  lungs;  b  d,  boundary  between  the  lungs  and  heart  at  the 
incisura  cardiaca.  The  strongly  hatched  surface  represents  the  portions  of  the  heart 
and  liver  that  are  in  contact  with  the  wall  of  the  chest;  the  lighter  hatching  the  so- 
called  relative  heart  and  liver  deadness  (see  later),     m.  Spleen  deadness. 

The  beginner  is  apt  to  be  much  confused,  because  in  a  considerable 
part  of  the  location  of  heart- dulness,  even  within  the  entire  region, 
he  will  find  a  tympanitic  resonance.  This  is  especially  frequent  in 
short  persons  with  a  short,  thick  thorax  and  a  full  abdomen.  The 
resonance  is  from  the  stomach,  which  lies  under  the  heart,  and  is 
more  promptly  elicited  by  strong  than  by  weak  percussion.  When 
there  is  an  otherwise  normal  condition  of  the  heart  and  lungs  this 
phenomenon  has  no  pathological  significance. 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.       207 

2.  Relative  heart- dulness.  This  forms  a  border  around  the  abso- 
lute dulness  to  the  left  and  above  it,  and  it  corresponds  with  the 
thinned-out  portion  of  the  lungs.  It  is  revealed  by  stronger,  and,  in 
its  upper  part,  by  comparative  percussion.  It  no  doubt  depends,  in 
a  certain  degree,  upon  the  perceptions  of  the  individual  making  the 
examination  as  to  where  he  will  fix  the  limits  between  it  and  those  of 
normal  lung  sound.  Hence,  an  individual  examiner  may,  if  he  is 
accustomed  to  examine  carefully  with  reference  to  its  determination, 
be  able  to  fix  upon  a  line  of  demarcation  very  satisfactorily  for  him- 
self, but  difierent  examiners  would  not  be  able  to  agree  among  them- 
selves. Hence,  the  difierences  among  authors  as  to  the  size  and  diag- 
nostic value  of  the  area  of  relative  heart-dulness. 

According  to  Weil,  its  course  is  as  follows  (see  Fig.  45) :  It  begins 
above  at  the  lower  border  of  the  third  rib,  continues  in  a  curve  down- 
ward toward  the  left,  within  the  mammillary  line.  In  rare  cases 
there  is  also  a  relative  dulness  at  the  right  of  the  absolute  dulness, 
which  is  limited  by  the  lower  end  of  the  sternum.  In  children  the 
relative  dulness  begins  in  the  third  intercostal  space,  it  extends  some- 
what beyond  the  left  mammillary  line,  and  is  also  constantly  present 
on  the  right,  and,  indeed,  reaches  even  beyond  the  right  side  of  the 
sternum. 

Whatever  may  be  the  meaning  and  value  which  these  two  regions 
■of  dulness  may  have  as  subjects  for  instruction  and  knowledge  for 
physicians,  there  is  no  doubt  that  at  least  that  of  absolute  dulness 
must  be  considered,  since  only  regarding  it  is  perfect  agreement  pos- 
sible, and  since  the  amount  of  time  and  trouble  which  every  student 
and  young  physician  can  and  must  employ  in  the  practice  of  percus- 
sion suffices  for  learning  how  to  determine  it. 

It  is  true,  that  in  pathological  cases  a  difficulty  accompanies  the 
determination  of  absolute  dulness ;  it  indicates  the  parietal  state  of 
the  heart,  but  this  is  dependent,  not  alone  upon  the  size  of  the  heart, 
but  also  upon  that  of  the  lungs,  though,  of  course,  in  an  opposite 
sense.  This  may  make  a  conclusion  regarding  the  size  of  the  heart 
from  the  extent  of  absolute  dulness  difficult ;  however,  a  person  who 
accustoms  himself  every  time  he  makes  an  examination  to  consider 
carefully  the  condition  of  the  lungs  when  he  is  determining  by  per- 
cussion the  figure  of  the  heart,  whether  there  is  emphysema  or  shrink- 
age— such  a  person  may  very  materially  diminish  this  difficulty. 


208  SPECIAL  DIAGNOSIS. 

Opinion  is  divided  regarding  Ebstein's  newer  method  of  determin- 
ing by  direct  palpatory  percussion  the  resistance  of  the  heart  as  the 
true  image  of  the  total  size  of  the  heart.  Indeed,  Eichhorst  is  the  only 
one  who  warmly  espouses  the  idea.  It  seems  to  me  that  there  is  no 
doubt  of  its  use  in  many  cases — that  is  to  say,  in  those  Avith  delicate 
thorax  having  thin  covering  of  flesh.  At  the  same  time  I  cannot 
recommend  it  as  a  subject  for  instruction  to  others,  since  it  is  liable 
-to  give  rise  to  many  mistakes,  and  in  my  opinion  "  •:  is  very  difficult  to 
learn. 

Riess  has  recently  very  strongly  entered  a  plea  for  relative  heart- 
dulness.  He  thinks  that  by  a  consideration  of  the  relative  dulness  a 
figure  could  be  drawn  which  would  very  nearly  represent  the  anatom- 
ical boundaries  of  the  heart.  We  think  this  is  going  much  too  far, 
and  that  we  must  maintain  the  position  that  we  have  set  forth 
above. 

3,  Method  of  percussing  the  heart.  We  percuss  strongly  on 
both  sides  close  to  the  sternum  going  downward,  and  note  the  upper 
boundary  of  relative  heart-dulness ;  then  we  percuss  lightly  the 
upper  boundary  of  absolute  heart-dulness  ;  next  we  percuss  upon  the 
outer  ends  of  radii  drawn  from  the  middle  of  what  is  thought  to  be 
area  of  absolute  dulness  (first  the  one  obliquely  upward  to  the  right, 
then  from  the  right,  always  beginning  beyond  the  sternum ;  then  on 
the  left  obliquely  upward  ;  lastly,  from  the  left),  always  strongly  at  first 
to  determine  a  possible  relative  dulness,  then  lightly  for  the  absolute. 
At  first  we  percuss  at  longer  intervening  spaces,  of  at  least  IJ  centi- 
metres, and  when  a  difference  of  resonance  is  found  then  at  short 
intervals  of  space  over  the  particular  region.  In  Fig.  45  the  lines 
and  the  directions  in  which  we  ought  to  percuss  are  designated  by 
arrows. 

Enlargement  of  the  Area  of  Heart-dulness. 

Generally,  relative  and  absolute  dulness  exist  in  about  equal  pro- 
portions, but,  now  and  then,  the  relative  may  be  very  small.  Always 
in  enlargement  of  the  right  side  of  the  heart,  and  sometimes  in 
enlargement  of  the  left  side,  relative  dulness  toward  the  right  is 
increased  as  compared  with  the  absolute. 

Heart-dulness  is  increased  : 

1.  In  hypertrophy  and  dilatation  of  the  heart.  If  of  the  right 
ventricle,  the  dulness  spreads  toward  the  right,  sometimes  also  slightly 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.       209 

toward  the  left,  the  whole  involving  the  right  half-circle.  If  the  left 
ventricle  is  changed,  the  increased  dulness  is  toward  the  left  and 
downward,  not  infrequently  also  upward,  but  scarcely  any,  or  at  most 
very  little,  toward  the  right.  Regarding  a  small  independent  dulness 
which  sometimes  is  found  on  the  right  near  the  upper  end  of  the 
sternum,  see  Aorta. 

2.  In  dilatation  of  the  heart  (weak  heart).  This  causes  the  pre- 
viously existing  dulness,  it  may  be  of  a  normal  heart  or  of  one  that 
was  already  hypertrophied,  to  spread  out  on  both  sides.  (For  dis- 
tinguishing from  hypertrophy  see  "apex-beat"  and  "  radial  pulse.") 

3.  Fluid  in  the  pericardium  {pericarditis  exudativa  and  hydro- 
pericardium).  Generally,  this  causes  the  dulness  to  enlarge  at  first 
upward  and  then  to  the  right  and  left.  Not  infrequently  the  area  of 
dulness  has  a  three-cornered  shape — one  point  above  close  to  the 
sternum,  one  on  the  right  on  the  other  side  of  the  sternum  below,  and 
one  on  the  left  also  below  on  the  outer  side  of  the  mammillary  line ; 
the  relative  dulness  is  generally  very  small.  If  the  exudation  is  very 
large,  the  lung  surrounding  it  is  generally  retracted,  and  hence  around 
the  dulness  there  is  a  border  of  tympanitic  resonance.  In  sitting,  the 
area  of  dulness  is  greater  than  in  lying,  and,  when  bending  forward, 
still  greater  than  in  sitting,  because  there  is  a  change  in  the  extent  of 
that  which  is  parietal. 

Regarding  the  apex-beat  in  pericarditis,  see  p.  202 ;  in  the  latter 
disease  it  is  often  deeper  and  not  on  the  left  border  cf  the  dulness,  as 
in  enlarged  heart,  but  further  toward  the  right  and  generally  within 
the  mammillary  line  (a  not  unimportant  point  in  differential  diagnosis). 
The  pulse  (which  see)  is  often  important. 

4.  When  the  heart  is  normal,  hut  is  to  a  greater  extent  parietal, 
on  account  of  retraction  of  the  lung.  In  this  case  the  mobility  of 
the  border  of  the  lungs  in  deep  breathing  is  completely  wanting. 
The  apex-beat  may  be  normal,  but  by  simultaneous  displacement  it 
is  further  to  the  left. 

5.  Apparent  enlargement  of  the  heart  is  noticed  if  anywhere  in  its 
neighborhood  there  is  a  diseased  condition  which  causes  absolute  dul- 
ness. Of  this  kind  we  may  name  thickening  of  the  lungs,  of  the 
pleura,  of  the  mediastinum,  and  especially  aneurism.  It  is  almost 
impossible  to  mark  the  boundary  between  the  heart  and  such  patho- 
logical structures,  since  we  are  denied  the  aid  of  percussion  ;  on  the 

14 


210  SPECIAL  DIAGNOSIS. 

other  hand,  an  approximate  determination  may  often  be  attained 
during  auscultation  by  the  appearances  of  motion  (apex-beat,  etc.), 
and  sometimes  by  the  vocal  fremitus. 

Pulsating  affections  give  especial  difficulty,  as  aneurism  and  the 
empyema  pulsans  previously  mentioned.  Here  the  object  is  some- 
times attained  by  repeated  examinations.  For  distinguishing  em- 
pyema pulsans  from  aneurism,  see  the  latter. 

Diminution  or  Loss  of  Heart-dulness. 

This  takes  place : 

1.  In  emphysema  of  the  lungs.  It  affects  the  parietal  condition  of 
the  heart,  whether  it  is  normal  or  enlarged.  If  the  heart  is  normal 
there  is  considerable  diminution  of  the  area  of  dulness,  even,  possibly, 
to  its  entire  disappearance.  If  the  heart  is,  at  the  same  time,  enlarged 
(as  it  has  already  been  mentioned,  it  generally  is  in  consequence  of  the 
emphysema,  which  causes  hypertrophy  of  the  right  ventricle),  the 
emphysema  makes  the  dulness  smaller  than  it  would  be  with  a  heart 
of  the  same  size  and  normal  lungs.  Hence,  when  there  is  emphysema 
we  must  make  some  addition  to  the  extent  of  the  dulness  we  are  able 
to  map  out  before  we  form  a  judgment  regarding  the  heart.  A  normal 
area  of  heart- dulness,  with  the  existence  of  a  marked  emphysema, 
indicates  considerable  hypertrophy  of  the  heart,  if  there  is  no  adhesion 
of  the  borders  of  the  lungs.  Hence,  we  must  notice  their  active 
movability. 

2.  In  pneumo-pericardium,  entrance  of  air  into  the  pericardium, 
either  from  without  by  an  external  injury  or  from  within  by  perfora- 
tion of  the  oesophagus,  stomach,  or  intestine,  we  may  have  the  condi- 
tion of  pneumothorax.  There  is  then  tympanitic  or  abnormally  loud 
and  deep  resonance  in  the  neighborhood  of  the  heart  (also,  metallic 
heart-sound).  Finally  (very  rarely)  in  emphysema  of  the  mediastinum. 
(See  p.  57.) 

Displacement  (dislocation)  of  the  Heart-dulness. 

This,  of  course,  arises  from  displacement  of  the  heart,  as  is  declared 
by  the  apex-beat ;  but  in  this  case,  for  various  reasons,  it  is  generally 
an  imperfect  sign  of  such  change.     For  one  thing,  it  often  happens 


EXAMINATION  OF  THE   CIRCULATORY  APPARATUS.       211 

that  the  condition  which  causes  the  dislocation  itself  presents  dulness, 
which  invades  the  region  of  heart- dulness.  This  is  the  case  when  a 
pleuritic  exudation  displaces  the  heart,  or  when  shrinking  of  the  pleura 
or  lungs  distorts  the  heart.  Again,  it  is  usually  especially  difficult  to 
determine  the  location  of  the  heart  by  percussion  if  there  exists  a 
vicarious  emphysema  on  the  left  side  simultaneously  with  considerable 
shrinking  on  the  right.  In  this  case  the  heart  is  sometimes  moved 
over  to  the  middle  of  the  thorax  [mesocardid). 

Still  further,  the  extent  to  which  the  heart  is  parietal  is  frequently 
changed  by  dislocation  ;  thus,  when  the  diaphragm  stands  very  high 
the  heart  is  pushed  upward,  usually  causing  an  increased  area  of 
dulness,  since  the  heart  is  then  more  flat  against  the  chest  than  is 
normal. 

If  there  is  an  apex-heat  in  such  cases,  it  is  a  very  sure  sign ;  often 
it  is  necessary  to  employ  auscultation  to  aid  in  establishing  by  the 
location  of  the  greatest  intensity  of  sound,  at  least  approximatively, 
the  position  of  the  heart. 

Auscultation  of  the  Heart. 

Method  and  Normal  Condition. 

Method.  Ordinarily  we  are  to  auscultate  the  heart  exclusively  by 
the  stethoscope.  After  long  practice  and  experience  the  examiner 
may  think  it  advisable  to  compare  what  he  hears  with  the  stethoscope 
with  the  results  of  direct  auscultation  ;  but  these  are  exceptions.  The 
very  urgent  reason  for  the  use  of  the  stethoscope  is  that  by  it  we  are 
able  to  distinguish  as  sharply  as  it  is  possible  to  do  the  impressions  of 
sound  which  come  from  the  different  points,  so  as  to  be  able  to  refer 
every  sign  to  its  proper  place  of  origin. 

First  of  all,  we  are  to  examine  the  patient  when  he  is  in  the  greatest 
possible  quietude  of  body  and  mind  ;  in  some  cases  we  may  then,  after 
we  have  begun,  find  it  advantageous  to  increase  the  activity  of  the 
heart  by  having  the  patient  make  a  certain  amount  of  exertion  (as  by 
sitting  up  in  bed  several  times  in  succession  or  moving  about),  since 
we  can  thus  sometimes  obtain  certain  signs  clearer.  This  will  be 
referred  to  from  time  to  time.  The  position  of  the  patient  during  the 
examination  will,  in  general,  be  the  same  as  for  percussion,  already 


212  SPECIAL  DIAGNOSIS. 

referred  to.  However,  we  often  hear  much  plainer  in  the  upright 
position,  and  hence  in  doubtful  cases  auscultation  in  this  position  is 
not  to  be  neglected. 

More  than  anywhere  else,  in  auscultation  of  the  heart  it  is  neces- 
sary to  examine  several  times.  The  rapidity  and  strength  of  the 
heart's  action,  and  possible  extraneous  sounds,  have  a  great  influence 
upon  the  distinctness  of  what  is  heard.  In  severe  diseases  of  the 
heart,  especially  with  heart-failure  from  different  causes  which  will  be 
mentioned,  the  impi-ession  is  generally  so  confused  that  no  physician 
of  experience  will  pronounce  a  definite  opinion  until,  by  appropriate 
treatment,  the  heart  has  been  restored  to  a  degree  of  strength. 

Normal  condition.  Over  the  whole  region  of  the  heart,  and  for  a 
certain  distance  beyond  it,  we  hear,  corresponding  with  each  pulsation 
of  the  heart,  two  "  sounds  " — one  coincides  with  the  ventricular  con- 
traction, the  "  systolic,"  the  "first"  sound:  one,  which  is  heard  at 
the  beginning  of  the  diastole,  the  "diastolic,"  the  "second"  sound. 
Corresponding  with  the  greater  duration  of  the  diastole,  the  pause 
between  the  second  and  the  following  first  sound  is  always  greater 
than  that  between  the  first  and  second. 

The  rliytlim  in  general  is  as  represented  here : 

12  12  12  12 

Syst.      Diast.       Syst.      Diast.       Syst.      Diast.       Syst.      Diast. 

The  apex-beat  coincides  in  time  with  the  systolic  sound,  and  like- 
wise, as  we  can  directly  observe,  with  the  pulse  in  the  common  carotid 
in  the  neck.  But  the  pulse  of  the  peripheral  arteries  occurs  notice- 
ably later,  so  that  the  radial  pulse  is  felt  between  the  first  and  second 
sounds  of  the  heart. 

The  expression  "  sounds  "  is  not  to  be  taken  in  a  strictly  acoustic 
sense.  In  reality  it  is  a  short,  sharply-defined  noise  which  only 
approaches  a  tone.  But  the  term  is  not  so  inappropriately  selected, 
as  everyone  must  be  impressed  who  compares  these  phenomena  of 
sounds  with  the  peculiar  hgart-sounds  to  be  spoken  of  hereafter. 

These  two — the  first  and  second  heart-sounds — can  be  heard  over 
the  whole  region  of  the  heart ;  but  at  different  points  they  are  of 
different  nature  and  origin,  as  is  partly  declared  by  the  character  of 
their  tone.  A  part  of  each  sound  has  its  origin  in  each  of  the  four 
portions  of  the  heart,  and  hence  is  in  all  eightfold : 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.       213 

1.  The  sudden  tension  and  closure  of  the  mitral  and  tricuspid 
valves  cause  a  systolic  sound,  which  naturally  is  most  distinctly  heard 
in  the  neighborhood  of  these  valves  or  over  the  ventricles. 

2.  The  closure  of  the  semilunar  aortic  and  pulmonary  valves  causes 
a  diastolic  flapping  tone,  heard  most  distinctly  over  those  valves  or  in 
their  neighborhood. 

3.  The  sudden  contraction  of  the  ventricle  causes  a  dull  systolic 
sound  of  short  duration. 

4.  The  sudden  filling  of  the  conus  arteriosus,  aortic  and  pulmonary, 
in  consequence  of  the  motion  of  the  blood,  or,  more  probably,  of  the 
sudden  tension  of  the  walls  of  these  vessels,  causes  a  short,  somewhat 
ringing  sound. 

Thus,  we  see  that  the  valves  have  a  very  essential  part  in  the  pro- 
duction of  the  heart-sound ;  and  since,  as  has  already  been  remarked 
in  the  "preliminary  observations"  [p.  194],  the  heart-sounds  arising 
in  certain  circumstances  are  orili/  connected  with  the  valves  or  the 
different  openings,  these  are  the  chief  consideration  in  auscultation. 
Hence,  we  have  chiefly  to  attend  to  the  auscultation  of  the  mitral 
valve,  the  mitral  orifice,  the  aortic  valve,  the  aortic  orifice,  etc. 

Hence,  it  follows  that  we  always  first  listen  at  those  four  points  of 
the  chest  which  lie  nearest  to  these  valves.  But  experience  has 
shown  that  for  two  of  these  this  is  not  the  best  method,  as  is  easily 
understood  from  the  anatomical  relations. 

We  cannot  auscultate  the  aortic  valves  at  the  point  of  the  chest 
which  lies  nearest  to  them,  since  they  are  obliquely  behind  the 
pulmonary  valves,  and  at  that  point  the  sound  which  comes  from  the 
pulmonary  artery  and  its  valves  predominates ;  hence,  we  must 
auscultate  at  the  beginning  of  the  aorta ;  and  we  do  nut  ordinarily 
hear  the  sounds  of  the  mitral  most  distinctly  at  the  point  where  it  is 
located,  since  a  layer  of  lung  there  covers  the  heart,  but  better  at  the 
apex  of  the  heart.  The  points  of  election  for  auscultating  the  heart 
are  as  follows  (compare  Fig.  46) : 

Mitral  valve,  1 

T    rv        •     1  .  •     1  ■        r  Apex  of  the  heart. 

Lett  auriculo-ventricular  openmg.  j     ^ 

Tricuspid  valve. 


T3 .  ,  ^        ■     T  ,  .     ,  .        r  Over  the  sternum. 

Kight  auricuio-ventricular  openmg. 

Aortic  semilunar  (ost.  aort.) :  2d  intercostal  space,  right  of  sternum. 

Pulm.  semilunar  (ost.  pulm.):  2d  intercostal  space,  left  of  sternum. 


214 


SPECIAL  DIAGNOSIS. 


The  accompanying  figure  exhibits  the  situation  of  the  openings  and 
the  points  where  they  may  be  best  auscultated.  We  see  that  the 
auscultation-points  of  the  mitral  and  aortic  valves  are  so  related  to  the 
respective  openings  that  they  lie  downward  from  them  with  reference 
to  the  normal  course  of  the  blood-current. 


Fig.  46. 


The  anatomical  situation  and  the  points  for  auscultating  the  valves  of  the  heart  and 
its  orifices.  The  small  letters  show  the  location  of  the  valves:  the  large  ones  the 
points  for  auscultating.  «^4  =:  the  aorta;  m3/^ mitral  valve;  j?P ^  the  pulmonary 
orifice;    ^T^ tricuspid. 

The  "  sounds"  that  can  be  heard  in  health  at  the  four  points  men- 
tioned correspond  with  the  occurrence  of  the  sounds  just  referred  to  in 
the  following  way : 

Apex  of  the  heart  (niitral  orifice)  : 

1st  sound :  Closure  of  the  mitral  valves  and  ventricular  contrac- 
tion. 
2d  sound  :  Prolonged  aortic  second  sound  (closure  of  aortic  valve). 
Under  the  sternum  (tricuspid  orifice)  : 

1st  sound :    Closure  of  the  tricuspid  valves  and  ventricular  con- 
■  traction. 

2d  sound :  Prolonged  pulmonary  second  sound. 
Second  intercostal  space  right  or  left  (aorta,  pulmoiiary  art.)  : 
1st  sound :  sudden  filling  of  the  beginning  of  the  aorta,  of  the 
pulmonary  artery,  and  continuation  of  the    first  ventricular 
sound. 
2d  sound  :  closure  of  the  semilunar  valves  of  the  aorta,  or  of  the 
pulmonary  artery. 
Thus  the  first  sound  is  a  mixed  one,  composed  of  muscle,  valve,  or 
also  of  vessel-sound ;  it  is  dull  and  somewhat  prolonged.     The  second 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS. 


215 


sound  is  throughout  wholly  from  the  semilunar  valves ;  it  is  short, 
flapping.  Hence  I  represent  the  first  by  a  dash,  the  second  by  a 
short  curved  line.  The  heart's  action  is  hence  represented  in  the 
following  way : 

Fig.  47. 


SI 


D2  S  D  S  D 

Representation  of  normal  heart-sounds. 


and  since  we  hear  the  second  sound  over  the  ventricle  only  as  con- 
ducted from  above  against  the  current  of  blood,  over  the  ventricle 
it  is  very  light,  hence  the  accent  at  the  apex  and  [over  the  sternum, 
i.  e.,]  under  the  sternum  is  represented  as  follows  : 


Fig.  48. 


In  auscultating,  however,  at  the  mouth  of  the  arteries  we  hear  the 
second  sound  at  the  place  of  its  origin ;  it  is  here  louder,  and  indeed 
louder  than  the  first,  and  hence  the  accent  is  at  the  base  of  the  heart : 


Fig.  49 


either 


or 

S  D  S  D  S  D  S 

according  as  the  first  sound  is  like  the  ventricular  tone  or  not. 

1  S  =  systole.  2  D=  diastole. 

3  This  representation  departs  from  the  habit  of  authors,  who  draw  the  comparison 
with  the  trochaic  and  iambic  foot,  and  this  does  violence  to  the  length  of  the  sounds, 
merely  for  the  sake  of  making  the  comparison.  I  maintain  that  the  above  representa- 
tion is  more  in  accordance  with  the  facts. 


216  SPECIAL  DIAGNOSIS. 

Differences  of  variations  within  normal  limits.  The  absolute 
strength  of  the  heart-sounds  varies  very  much  in  persons  in  health. 
It  depends  upon  the  elasticity  and  delicacy  of  the  thorax :  children 
and  persons  with  delicate  thorax  generally  have  loud  heart-sounds ; 
with  the  former  (children),  they  are  widely  conducted  by  the  lungs, 
and  this  for  the  same  reason  that  with  them  the  breathing-sound  is 
sharper  (see).  Further,  the  thickness  of  the  covering  of  the  chest  has 
its  effect:  large  mammae,  thick  layer  of  fat,  weaken  the  sounds.  Tem- 
porary excitement  of  the  heart  may  increase  the  sounds  so  very  much 
that  even  an  experienced  person  may  be  tempted  to  suppose  that  they 
are  increased  by  pathological  conditions. 

The  tone  of  the  heart-sounds  also  varies  :  with  many  the  first  sound 
as  well  as  the  second  is  more  "tone-like,"  with  others  less  so.  Espe- 
cially variable  are  the  first  sounds :  sometimes  shorter,  sometimes 
longer,  noise-like,  "impure";  further,  sometimes  very  deep  and  not 
clear,  "dull." 

The  first  sound  of  the  heart  (much  more  rarely  the  second)  may 
even  in  health  be  doubled: 

Fig.  50. 


S  D  S  D 

Normal  first  sound  doubled. 


This  is  generally  only  at  the  end  of  expiration  and  the  beginning  of 
inspiration,  probably  disturbed  by  the  ventricles  not  contracting  syn- 
chronously (see  also  under  Pathological  Doubling). 

Regarding  the  measurement  of  the  heart-sounds  see  page  217. 

Pathological  Changes  in  the  Heart- sounds. 

General  strengthening  of  the  sounds  indicates  increased  activity 
of  the  heart:  this  may  occur,  as  above  indicated  regarding  healthy 
persons,  but  to  a  still  higher  degree,  from  temporary  excitement  in 
nervous  disease  of  the  heart,  and  also  in  Basedow's  disease ;  it  is  also 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.        <211 

a  frequent  accompaniment  of  fever — this  without  the  heart  being 
hypertrophied.  But  also,  it  corresponds  with  the  increased  work  of  the 
heart  in  hypertrophy,  especially  of  the  left  ventricle ;  and  we  meet  a 
strength  and  hence  often  a  flapping  character  of  sound  not  infre- 
quent in  ancemia,  and  especially  in  chlorosis. 

Strengthened  heart-sounds  are,  as  a  matter  of  course,  heard  over  a 
larger  area  beyond  the  heart  than  normal.  They  may  be  heard  over 
the  Avhole  thorax.  However,  such  more  extended  perception  of  heart- 
sounds  may  be  due  to  condensation  of  the  lungs  (pneumonia,  chronic 
contracting  phthisis). 

It  is  difficult  to  measure  exactly  the  strength  of  the  sounds  of  the 
heart.  Recently  a  very  ingenious  method  has  been  proposed  by  H, 
Vierordt.  Its  significance  will  be  greatly  aifected  by  the  changing 
dulling  eifect  of  the  chest-wall  and  its  covering,  also  of  the  lungs.  It 
is  interesting  to  note  that  normally  the  mitral  first  sound  is  the  loudest 
and  the  aortic  first  sound  the  softest.  Dull  sounds,  which  by  the  usual 
mode  of  auscultation  the  ear  is  accustomed  to  consider  light,  by  this 
method  sometimes  manifest  themselves  as  louder,  like  flapping,  thus 
apparently  more  intense. 

Strengthening  of  separate  sounds.  Strengthening  of  a  second  sound 
(more  emphatic  closure  of  the  semilunar  valves),  if  persistent,  is  a 
very  sure  sign  of  hypertrophy  of  the  corresponding  ventricle.  Only 
we  must  not  consider  a  slight  emphasis  of  the  aortic  or  pulmonary 
second  sound  as  a  pathological  strengthening.  (Regarding  the  con- 
ditions which  lead  to  hypertrophy  of  the  ventricle  see  the  Preliminary 
Remarks.)  Abnormally  strong,  accentuated  pulmonary  second  sound 
is  thus  a  very  important  sign  of  hypertrophy  of  the  right  ventricle, 
and  it  is  the  more  important  since  in  this  condition  percussion  is  often 
doubtful.  Strengthened  aortic  second  sound,  especially  in  sclerosis 
of  the  aorta,  becomes  slightly  sonorous,  ringing.  In  hypertrophy 
of  the  left  ventricle  from  insufficiency  of  the  aortic  valves  accentua- 
tion is  wanting,  because  in  the  main  the  second  sound  is  wanting, 
since  the  valves  do  not  close. 

This  accentuation  of  the  second  sound  immediately  disappears  when 
the  heart  becomes  weak,  when  heart  failure  takes  place.  The  disap- 
pearance of  the  accentuation  of  the  pulmonary  second  sound  is  there- 
fore of  especial  diagnostic  value,  since  we  have  no  other  direct  sign  of 


218  SPECIAL  DIAGNOSIS. 

commencing  failure  of  tlie  right  ventricle.  If  there  occurs  a  relative 
tricuspid  insufficiency  from  a  high  degree  of  weakness  and  dilatation 
of  the  right  ventricle  (see  Preliminary  Remarks),  then  the  pulmonary 
second  sound  almost  entirely  fails,  since  the  blood  now  has  an  outlet 
upon  both  sides,  backward  through  the  ostium  venosum,  and  forward 
into  the  pulmonary  artery,  and  thus  the  pulmonary  pressure  falls  off 
very  greatly. 

In  a  case  of  disease  of  the  heart  the  importance  of  the  second  pul- 
monary sound  cannot  be  too  strongly  impressed  upon  the  beginner  in 
making  his  observations ;  it  is  a  measure  of  the  activity  of  the  right 
ventricle,  as  the  pulse  is  of  the  work  of  the  left  (see  Pulse). 

Not  infrequently  both  pulmonary  sounds  (much  less  frequently  hoth 
aortic  sounds)  are  strengthened  because  the  base  of  the  heart  is  in  con- 
tact with  the  chest-wall,  when  there  is  shrinking  of  the  lungs.  An 
accented  pulmonary  second  sound  from  hypertrophy  of  the  right  ven- 
tricle may  he  felt  thus  as  a  diastolic  stroke  in  the  left  second  intercostal 
space.  The  author  once  found,  in  a  case  of  mitral  insufficiency  with 
hypertrophy  of  the  left  ventricle  with  shrinking  of  the  lung,  an  aortic 
second  sound  that  could  be  felt  in  the  right  second  intercostal  space. 

Pathological  strengthening  and  flapping  character  of  the  first  sound 
at  the  apex  are  so  frequently  occurrences  in  mitral  stenosis  that  to  the 
experienced  observer  they  have  diagnostic  value.  The  phenomenon 
is  ordinarily  explained  as  being  a  consequence  of  diminished  filling  of 
the  left  ventricle  which  follows  from  the  lessened  size  of  the  orifice  by 
which  it  is  filled,  the  segments  of  the  mitral  valve  at  the  end  of  the 
diastole  are  still  very  lax,  and  so  come  together  with  more  energy  at 
the  beginning  of  the  systole.  This  explanation  does  not  appear  to  us 
to  be  wholly  acceptable. 

Weakness  of  all  the  sounds  of  the  heart  (more  inclined  to  concern 
the  second  sounds)  occurs  in  all  cases  of  weak  heart-,  as  takes  place 
in  hearts  previously  sound  in  consequence  of  over-exertion,  severe 
hemorrhages,  carbonic  acid  poisoning,  or  any  kind  of  interference 
with  breathing  (see),  any  other  kind  of  poison,  as  heart  poison,  in 
acute  febrile  diseases ;  finally,  in  central  or  peripheral  paralysis  of 
the  vagus,  as  follows  disease  of  the  heart-muscle,  or  as  generally  at 
last  from  some  cause  or  other  overtakes  an  hypertrophied  heart. 

Hypertrophy  of  one  division  of  the  heart  is,  as  referred  to  in  the 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.       219 

Preliminary  Remarks,  generally  '■^compensatory'' — that  is,  it  is  said 
to  accompany  any  obstruction  of  the  circulation.  If  a  hypertrophic 
heart  can  no  longer  meet  the  demands  made  upon  it,  we  then  use  the 
term  "  incompensation."  Then  heart-sounds  that  in  part  were  pre- 
viously strengthened  at  first  become  about  normal,  and  then  become 
weaker  than  normal. 

Moreover,  when  an  emphysematous  lung  forms  a  layer  over  the 
heart,  the  heart- sounds  are  found  to  be  persistently  weakened,  even  to 
marked  indistinctness,  and  this  involves,  also,  the  pulmonary  second 
sound,  which,  in  emphysema,  is  strengthened.  This  weakening  occurs 
with  large  'pericardial  exudations  or  hydro-pericardium  ;  more  rarely 
from  a  tumor  or  pleural  exudation  pressing  against  the  heart. 

Weakening  of  individual  sounds.  If  there  is  an  "  organic  heart 
murmur"  (see  p.  221),  then  the  sound  with  w^hich  it  occurs,  or  at  which 
it  ceases,  becomes  either  weakened  or  indistinct,  or  it  is  entirely  wanting, 
so  that  the  "murmur"  takes  the  place  of  the  sound.  But  also  with 
certain  valvular  defects  there  occurs  weakening  of  other  sounds,  such 
as  of  the  aortic  second  sound  in  mitral  stenosis.,  in  consequence  of 
which  the  left  ventricle  has  only  a  little  blood  to  throw  into  the  aorta 
(see  Preliminary  Remarks) ;  weakening  of  the  same  aortic  second  sound 
in  stenosis  of  the  aorta,  as  the  pulmonary  second  sound  in  ste7iosis  of 
the  pulmonary  artery,  as  a  consequence  of  those  valves  being  less  free 
in  their  action.  Not  without  diagnostic  value,  also,  is  a  high  degree  of 
weakening  (even  to  complete  disappearance)  of  the  first  sound  at  the 
apex  in  aortic  insufficiency.  This  is  explained  by  the  reflux  from  the 
aorta,  with  the  normal  afflux  from  the  auricle,  filling  the  ventricle 
abnormally  full ;  it  becomes  dilated,  and  thus  the  tips  of  the  mitral 
valves,  even  before  the  beginning  of  the  systole,  are  somewhat  pushed 
up.  When  the  systole  takes  place,  there  is  then  only  a  moderate 
increase  in  its  tension.  Moreover,  in  aortic  insufficiency,  over  the 
aorta  the  first  sound  is  often  weak  and  very  impure,  without  other 
contemporaneous  signs  of  aortic  stenosis  being  present,  (See  Heart 
Murmurs,  and  Pulse.) 

Divided  or  double  heart-sounds.  These  ordinarily  are  without  sig- 
nificance if  the  condition  otherwise  is  one  of  health  (see  p.  217).  They 
occur  also  in  pathological  conditions,  and  are  then  of  diagnostic  mean- 
ing.    We  bring  together  here  (Fig.  51)  the  cases  in  which,  instead  of 


220 


SPECIAL  DIAGNOSIS. 


two  heart-sounds  we  hear  three,  without  sharply  separating  between 
"divided''  and  "doubled"  sounds. 

Division  of  the  second  sound  at  the  apex  occurs  in  mitral  stenosis. 
It  may  conceal  a  diastoHc  sound,  which,  with  the  patient  in  the  up- 


(Divided :) 


Fig.  51. 


(Doubled: ) 


Different  kinds  of  division  and  doubling  of  the  heart  sounds. 

right  position  and  heart  excited,  sometimes  can  only  be  distinctly 
heard  by  placing  the  stethoscope  at  the  outer  left  end  of  the  apex-beat. 
We  may  especially  refer  a  divided  second  sound  at  the  apex,  accord- 
ing to  my  experience,  to  mitral  stenosis,  in  case  there  are,  besides, 
undoubted  signs  of  mitral  insufficiency. 

Further,  a  divided  second  sound  h  heard  in  pericarditis  adhesiva 
and  systolic  retraction  of  the  apex-beat.  (Friedreich's  explanation 
of  the  phenomenon  may  be  doubted.) 

Finally,  here  belongs  the  gallop  rhythm,  sometimes  present  : 

Fig.  52. 


or  also : 


s  s 

Gallop  rhythm. 


that  is,  three  similar  short  ringing  sounds,  of  which  either  the  second 
or  third  has  an  accent,  but  in  many ,  cases  neither  has  an  accent.. 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.       221 

This  gallop  rhythm  may,  but  quite  exceptionally,  be  observed  in 
health  with  excited  action  (I  have  seen  two  cases).  It  is  also  observed 
in  emphysema,  contracted  kidney,  arterial  sclerosis,  heart  disease  with 
slight  incompensation.  But  it  generally  indicates  severe,  often  fatal 
heart-failure,  and  especially  in  infectious  diseases.  It  is  particularly 
frequent  in  children  ;  it  may  here,  for  example,  in  diphtheria,  be  the 
first  sign  of  beginning  paralysis  of  the  heart,  even  before  the  pulse 
becomes  markedly  quickened.  In  my  opinion  the  gallop  rhythm  may 
be  explained  in  the  same  way  as  the  divided  sound,  the  ventricles  not 
contracting  at  the  same  time.  This  question  will  be  variously  an- 
swered by  different  authors. 

Metallic  heart-sounds.  They  come  from  the  resonance  of  a  large 
smooth-walled  layer  of  air  close  over  the  heart,  as  is  the  case  in 
pneumo-pericardium,  not  infrequently  in  pneumothorax,  and  in  indi- 
vidual cases  of  large  cavity  in  the  lung  with  smooth  walls  which  lies 
close  to  the  heart.  Intestinal  or  peritoneal  meteorism  (see  both  of 
these),  or  a  very  much  inflated  stomach,  may  sometimes  cause  metallic 
heart-sounds. 

In  pneumo-pericardium,  also  in  cases  of  inflation  of  stomach  with 
gas,  if  the  action  of  the  heart  is  very  strong  or  excited,  the  sounds 
may  be  so  loud  that  the  first,  or  even  the  first  and  second,  can  be 
heard  at  a  distance. 

Organic  Endocardial  Heart-murmurs. 

By  endocardial  heart-murmurs,  as  the  name  implies,  we  understand 
murmurs  arising  within  the  heart  in  distinction  from  those  arising  in 
the  pericardium.  Endocardial  murmurs  are  again  distinguished  as 
organic  and  inorganic,  according  as  they  are  dependent  upon  anatomical 
changes  or  not.     We  now  consider  the  former. 

Organic  heart-murmurs  will  be  caused  by  stenosis  of  the  openings 
or  by  imperfect  closure  of  the  valves  or  insufficiency,  both  the  ordinary 
and  the  relative  insufficiency  of  the  valves  (see  Preliminary  Remarks, 
paragraph  2).  They  furnish  us  with  an  important  means  of  recogniz- 
ing the  so-called  valvular  defects. 

If  fluid  is  flowing  through  a  tube  which  suddenly  at  a  certain  point 
is  contracted,  from  this  stenosis  eddies  in  the  current  will  arise  below 
that  point,  and  these  eddies  will  cause  murmurs.     If  the  fluid  flows 


222  SPECIAL  DIAGNOSIS. 

very  rapidly  the  eddies  and  their  sounds  are  increased.  Normally 
the  blood  passes  through  the  openings  of  the  heart  v/ithout  sound, 
since  there  is  no  notable  narrowing  of  the  course  of  the  blood ;  but  if 
an  opening  is  narrowed^  then  eddies  and  sounds  are  produced,  and  so 
much  the  more  markedly  if  there  is  compensation,  when  the  blood 
from  the  section  of  the  heart  lying  behind  the  narrowed  opening  is 
driven  with  much  greater  rapidity  than  normal  through  the  narrowed 
opening  (see  Preliminary  Remarks). 

Such  a  murmur  will  be  heard  at  the  moment  when  normally  the 
blood  passes  through  that  opening — that  is,  at  the  systole,  if  an  arterial 
opening  is  narrowed,  at  the  diastole  if  a  venous  opening  is  affected 
(auriculo-ventricular). 

But  murmurs  are  produced  by  insufficiency  of  the  valves,  which  are 
to  be  explained  in  the  following  way :  The  effect  of  insufficiency  is 
such  that  the  blood,  which,  in  the  preceding  stage  of  the  heart's  action, 
passes  through  the  affected  opening,  in  the  following  stage,  iu  which 
the  valves  of  that  opening  would  have  closed,  partly  flows  back ;  it 
likewise  flows  against  the  blood  normally  flowing  into  the  cavity  and 
rebounds  with  it :  thus  eddies  arise  and  also  a  murmur.  The  intensity 
of  this  murmur  depends,  in  the  first  place,  upon  the  degree  of  insuf- 
ficiency, and,  again,  very  materially  varies  with  the  strength  of  the 
heart's  action  ;  for  the  greater  this  is  the  more  marked  is  the  differ- 
ence in  pressure  and  the  more  violent  the  backward  current  which  it 
causes. 

Likewise,  there  occurs  the  murmur  of  insufficiency  in  that  stage  of 
the  heart's  action  in  which  the  affected  valves  ought  normally  to  close 
— that  is,  at  the  arterial  openings  with  the  diastole,  and  at  the  venous 
openings  with  the  systole. 

Moreover,  it  appears  to  me  to  be  unquestionable  that,  in  the  great 
majority  of  cases  of  insufficiency,  the  murmur  is  increased  by  the 
simultaneous  occurrence  of  a  murmur  from  stenosis ;  for  the  reflux 
current  of  blood  certainly  flows  through  a  narrowed  opening  if  the 
insufficiency  is  not  greater  than  it  usually  is.  I  also  think  that,  in 
connection  with  this,  in  cases  of  severe  aortic  insufficiency  (N.  B  ,  with 
full  compensation),  we  find  the  diastolic  murmur  especially  soft.  (See 
further  regarding  this  the  following,  upon  the  influences  that  aflect 
the  loudness  and  character  of  the  heart-murmurs.) 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.       223 

Loudness  of  the  endocardial  murmurs.  From  what  has  already 
been  said  it  is  evident  that  the  loudness  of  the  murmur  is  not  alone 
dependent  upon  the  severity  of  the  valvular  lesion.  It  is  also  a  very 
great  mistake  to  draw  a  conclusion  about  the  degree  of  the  stenosis  or 
insufficiency  from  the  loudness  of  the  murmur;  regarding  this,  the 
eifects  of  the  valvular  lesions  upon  the  heart  and  circulation,  especially 
the  pulse  (which  see),  are  much  more  determinative. 

Murmurs  are  very  much  affected  by  the  strength  of  the  action  of 
the  heart :  they  are  plainly  louder  when  the  heart  is  excited,  and  hence 
when  they  are  indistinct,  if  the  patient  is  able  to  do  so  and  is  not 
harmed  by  it,  he  can  first  move  about  or  can  sit  up  and  lie  down 
again  several  times  in  bed  before  we  auscultate  him.  On  the  contrary, 
a  murmur  previously  distinct  becomes,  without  exception,  more  feeble 
if  the  strength  of  the  heart  declines.  In  very  marked  weakness  of 
heart  the  murmur  may  even  become  entirely  imperceptible,  hence,  in 
disease  of  the  heart,  the  murmurs  entirely  disappear  if  an  unfavor- 
able turn  takes  place  ;  also,  they  disappear  in  cases  of  heart  disease 
Avhere  tha  patient  is  overtaken  with  a  severe  febrile  disease  (see  above). 
Hence,  an  exact  diagnosis  of  disease  of  the  heart,  if  the  heart  is  weak, 
is  always  uncertain,  and  often  impossible,  whenever  the  action  of  the 
heart  is  accelerated.  (See  Relation  of  Heart-murmurs  to  the  Time  of 
Action  of  the  Heart,  p.  224.)  Hard  (calcareous)  or  rough  valves  have 
the  effect  of  strengthening  or  sharpening  the  murmurs  of  stenosis,  or, 
perhaps,  also  of  insufficiency ;  also,  in  individual  cases,  the  murmur 
may  be  changed  by  the  relaxation  or  rupture  of  the  tendinous  cords 
of  the  valves  (see  Character  of  the  Murmurs).  In  other  respects  the 
strength  of  the  murmurs  is  dependent  upon  the  same  influences  as 
affect  the  heart-sounds  (which  see). 

In  rare  cases  the  heart-murmur  is  so  marked  that  it  may  be  heard 
at  a  distance,  without  laying  the  ear  over  the  chest.  Such  murmurs 
may  sometimes  be  perceived  by  the  patient.  Only  those  arising  at 
the  aortic  orifice  have  this  peculiarity. 

Localization  of  the  murmurs.  The  next  diagnostic  point  of 
importance  is  that  we  can  determine,  from  the  location  in  the  region 
of  the  heart  where  a  murmur  can  be  heard  most  distinctly  or  where  it 
is  loudest,  whence  it  arises — that  is,  at  which  opening  the  valves  are 
diseased.  The  auscultation-points  already  mentioned  serve  here  as 
points  of  departure.     We  listen — 


224  SPECIAL  DIAGNOSIS. 

At  the  apex  of  the  heart — that  is  to  say,  at  the  point  of  the  apex- 
beat — for  the  mitral  valve,  the  left  venous  opening. 

Over  the  lower  part  of  the  sternum — for  the  tricuspid  valve,  the 
right  venous  opening. 

In  the  right  second  intercostal  space,  close  to  the  sternum — for  the 
[aortic]  opening  and  the  auricular  semilunar  valves. 

In  the  left  second  intercostal  space,  close  to  the  sternum — for  the 
opening  [of  the  pulmonary  artery]  and  the  pulmonary  semilunar 
valves. 

But  it  is  to  be  noticed  that  the  murmur  caused  by  aortic  insufficiency 
is,  as  a  rule,  not  heard  in  the  right  second  intercostal  space,  but  is 
most  distinct  over  the  sternum,  sometimes  even  in  the  left  third  inter- 
costal space  at  the  left  of  the  sternum;  since  it  is  caused  by  the 
backward  flow  of  the  blood,  it  is  conducted  in  the  direction  of  the 
ventricle.  Analogously,  but  only  exceptionally,  the  murmur  of  insuf- 
ficiency of  the  mitral  valves  may  be  noticed  most  markedly,  not  at  the 
~apex,  "but  on  the  left  of  the  base  of  the  heart — that  is,  in  case  the 
dilated  left  auricle,  with  its  appendage,  lies  somewhat  forward 
(Naunyn). 

The  murmur  of  stenosis  of  the  left  auriculo-ventricular  open- 
ing is  often  distinctly  heard  close  to  the  outer  edge  of  the  apex- 
beat. 

Relation  of  the  heart-murmurs  to  the  time  of  action  of  the  heart. 
It  follows  from  the  above  discussion  that  the  organic  heart-murmurs 
are  very  closely  connected  with  certain  instants  of  the  action  of  the 
heart,  and,  further,  that  they  are  divided  into  systolic  and  diastolic. 
And  thus  we  hear  in — 

Stenosis  of  the  aorta:  A  systolic  murmur  in  the  right  second 
intercostal  space. 

Fig.  53. 


Aortic  insufficiency:   A  diastolic  murmur  at  the  same  place,  or, 
better,  lower  down  to  the  left  of  this,  over  the  sternum. 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.       225 
Fig.  54. 


Mitral  stenosis :  A  diastolic  murmur  at  the  apex,  the  first  sound 
being  accentuated ;  or  approximately  so,  if  the  second  sound  is 
heard  at  all.     (See  more  exactly  below). 


Fig.  55. 


Mitral  insufficiency/:  A  systolic  murmur  at  the  apex  of  the  heart. 

Pig.  56. 


or: 


Quite  analogously,  m  pulmonary  stenosis  and  tricuspid  insufficiency, 
we  hear  a  systolic  murmur,  in  pulmonary  insufficiency  and  tricuspid 
stenosis,  a  diastolic  murmur  at  the  corresponding  points  (see  above). 
Of  these  valvular  defects  of  the  right  side  of  the  heart  the  only  one 
frequently  present  is  tricuspid  insufficiency,  and  this  is  relatively 
much  more  frequent  (in  great  weakness  of  the  heart)  than  insufl&ciency 
caused  by  endocarditis.  Pulmonary  insufficiency  and  stenosis  are 
almost  always  congenital,  and  then  are  very  often  associated  with  a 
permanently  open  foramen  ovale  (regarding  which  see  later). 

Systolic  murmurs  in  stenosis  of  the  aorta  and  insufficiency  of  the 
mitral  valve,  and  the  diastolic  murmur  from  aortic  insufficiency 
generally  are  directly  joined  with  the  sound  affected  by  them ;  but 

15 


226 


SPECIAL  DIAGNOSIS. 


these  sounds  are  thus  always  weakened,  or  the  sound  completely  dis- 
appears and  the  murmur  takes  its  place.  In  such  cases  the  sound 
may  still  be  heard  if  we  remove  the  ear  a  short  distance  from  the  ear- 
plate  of  the  stethoscope.  Probably  the  Aveakened  sound  is  not  to  be 
referred  to  the  valve  that  is  affected,  but  is  conducted  so  as  to  be 
heard  elsewhere. 

On  the  other  hand,  a  peculiar  condition  commonly  belongs  to  the 
diastolic  murmur  of  mitral  stenosis ;  it  occurs  at  the  end  of  the 
diastole  as  a  ^o-cdWedi  presystolic  murmur,  or,  in  case  it  is  present  at 
the  beginning  of  the  diastole,  it  becomes  stronger  toward  the  end; 
hence,  either: 

Fig.  57. 


or; 


The  explanation  of  this  remarkable  phenomenon  is  very  simple : 
toward  the  end  of  the  diastole  the  auricle  contracts  and  drives  the 
blood  with  greater  rapidity  through  the  narrow  ostium  venosum ; 
hence,  the  strengthening  of  tKe  eddy  and  murmur. 

In  most  cases  a  little  practice  enables  one  to  recognize  in  what 
period  of  the  action  of  the  heart  an  endocardial  murmur  belongs.  But 
if  there  remains  the  slightest  doubt  whether  a  murmur  is  systolic  or 
diastolic,  then  the  examiner  must  observe  the  action  of  the  heart  by 
palpating  at  the  same  time  he  is  auscultating,  and  this  is  best  done  by 
applying  a  finger  to  the  common  carotid  in  the  neck  ;  here  the  pulse 
is  almost  simultaneous  with  the  ventricular  systole,  and  hence 
demonstrates  the  time  of  its  occurrence. 

We  cannot  employ  the  radial  pulse,  because  it  is  felt  too  long  after 
the  systole.  When  the  action  of  the  heart  is  very  irregular,  and 
still  more  when  it  is  very  much  accelerated,  it  is  very  difiicult,  or  it 
may  be  entirely  impossible,  to  distinguish  between  systole  and 
diastole. 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS         227 

Murmurs  differ  very  much  in  character :  murmurs  of  insufficiency 
are,  as  a  rule,  softer,  blowing,  and,  indeed,  the  murmur  of  aortic 
insufficiency  manifests  itself  often  by  its  length  and  remarkable 
delicacy  (it  may  easily  be  overlooked),  while  that  of  mitral  insufficiency 
usually  is  louder,  but  not  quite  so  long.  Of  the  murmurs  of  stenosis, 
that  of  the  aorta  is  generally  loud,  "  sawing  "  ;  mitral  stenosis,  on  the 
other  hand,  is  almost  always  very  soft,  peculiarly  rolling  or  "flowing," 
or  seeming  to  consist  of  several  very  soft  sounds.  This  murmur  is 
sometimes  imperceptible,  even  with  strong  action  of  the  heart. 

Under  some  circumstances  aortic  or  mitral  murmurs  of  insufficiency 
may  be  musical — that  is,  they  contain  a  sound  which  approaches  a 
distinct,  always  very  high  musical  tone.  In  such  cases  there  have 
frequently  been  found  at  the  autopsy  the  suspected  causes  of  this 
phenomenon  in  that  the  semilunar  valve  has  been  found  to  be  per- 
forated, also  torn  floating  shreds  of  valves,  sinewy  threads  in  the 
lumen  of  the  ventricle,  floating  torn  shreds  of  papillary  muscle,  etc. 
These  conditions  generally  furnish  no  indication  as  to  the  particular 
heart-lesion  ;  it  is,  therefore,  of  no  value  to  recognize  them  during 
life.  In  many  cases,  moreover,  of  which  two  came  under  my  own 
observation,  it  happens  that  at  the  autopsy  nothing  is  found  to  explain 
the  occurrence  of  the  musical  murmurs  during  life. 

Metallic  murmurs  occur  under  the  same  conditions  as  metallic 
heart-sounds  (see) :  in  general,  if  there  is  a  resonant  air-space  near  to 
the  heart. 

Murmurs  that  may  he  felt :  endocardial  whizzing,  "fr^missement 
cataire,"  cat's  purring.  This  occurs  generally,  but  by  no  means 
always,  with  murmurs  that  are  distinguished  by  their  loudness. 
Locally,  their  most  distinct  perception  by  touch  always  corresponds 
with  the  locations  where  they  are  heard  most  distinctly.  We  palpate, 
with  the  hand  or  finger-tips  and  recognize  thus,  though  only  in  rare 
cases,  a  fine  whizzing,  which  is  most  like  what  we  feel  when  we  stroke 
the  back  of  a  purring  cat. 

In  this  way,  by  the  aid  of  palpation,  we  may  prove  the  existence 
at  the  apex  of  systolic  and  diastolic,  or  presystolic  mitral  murmurs, 
and  in  the  right  second  intercostal  space  of  systolic  and  diastolic 
aortic  murmurs.  Defects  of  the  right  heart  seldom  produce  murmurs 
that  can  be  felt.      The   palpation   of  endocardial  murmurs   has  so 


228  SPECIAL  DIAGNOSIS. 

subordinate  a  value  that  we  can  never  permit  ourselves  to  dispense 
with  auscultation,  which  yields  so  much  sharper  and  clearer  results. 

Transmission  of  heart-murmurs.  It  is  understood  that  an  endo- 
cardial murmur  is  very  often  not  confined  to  that  spot  on  the  thorax 
where  it  is  auscultated,  but  will  be  heard  at  some  distance  away  from 
it.  The  conduction  takes  place  especially  in  the  direction  of  the  blood- 
current.  Thus  an  aortic  systolic  murmur  is  often  heard  even  over 
the  carotid  in  the  neck.  On  the  other  hand,  the  diastolic  aortic 
murmurs  generally  are  perceived  over  the  sternum,  even  louder  than 
in  the  right  second  intercostal  space ;  but  they  are  also  often  to  be 
heard  as  far  down  as  the  apex.  Systolic  blowing  in  mitral  insufii- 
ciency  is  sometimes  conducted  toward  the  right  as  well  as  further 
upward.  On  the  other  hand,  diastolic  [presystolic]  murmur  from 
mitral  stenosis  is  always  sharply  confined  to  the  left  border  of  the 
heart.  An  inorganic  systolic  -pulmonary  murmur  which  can  be 
heard  some  distance  downward  from  the  base  of  the  heart  very  often 
disturbs  or  deceives  us. 

Qomhination  of  several  murmurs.  This  results  from  the  combina- 
tion of  several  valvular  defects.  It  more  frequently  happens  that 
insufficiency  of  a  valve  is  connected  with  stenosis  of  the  opening  to 
which  that  valve  belongs.  Then  we  hear  at  a  particular  spot  a 
murmur  with  each  of  the  two  stages  of  the  heart's  action.  It  is  more 
difficult  to  interpret  what  is  heard  when  the  disease  afl"ects  different 
openings  or  valves,  and  especially  if  there  are  two  murmurs  both  of 
which  occur  with  the  systole  (mitral  insufficiency  and  aortic  stenosis), 
or  both  in  the  diastole  (mitral  stenosis  and  aortic  insufficiency).  Then, 
it  may  happen  that  only  one  valve  is  supposed  to  be  diseased  and  that 
the  second  murmur  which  is  heard  is  transmitted  from  the  first.  But 
also  a  mistake  in  the  opposite  direction  may  be  possible,  namely,  that 
we  assume  that  there  is  a  combination  of  two  valvular  affections  when 
in  fact  there  is  only  one,  as  when  a  murmur  of  aortic  insufficiency 
which  is  heard  at  the  apex  is  considered  as  a  new,  independent  mur- 
mur produced  by  mitral  stenosis.  The  differentiation  by  auscultation 
is  made  in  two  ways  :  1.  By  the  character  of  the  murmur.  If  one  is 
blowing  and  the  other  is  rough  there  certainly  are  two  murmurs ;  if 
both  are  alike  then  there  may  be  only  one,  which  is  conveyed  from 
the  opening  where  it  arises  to  a  second  opening.  Yet  it  might  be 
that  even  in  this  case  there  were  two  murmurs,  with  different  origin. 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.        229 

2.  We  auscultate  step  by  step  from  the  point  where  we  can  hear  one  to 
where  the  other  exists,  as  from  the  apex  to  the  aorta.  If  the  murmur 
is  everywhere  distinct,  only  that  toward  one  spot  it  gradually  becomes 
louder,  then  it  arises  at  this  point  and  is  conveyed  to  another.  But 
if  it  is  lost  somewhere  on  the  way  from  the  apex  to  the  aorta  and  is 
again  heard  at  the  aorta,  then  there  are  two  murmurs. 

This  procedure  may  answer  the  purpose,  but  it  often  fails,  and  in 
such  difficult  cases  auscultation  alone  cannot  decide,  but  we  must  take 
a  view  of  the  whole  picture  of  the  heart  and  vessels  in  order  to  reach 
a  diagnosis.     This  will  be  treated  of  further  on. 

Finally,  murmurs  that  arise  in  the  neighborhood  of  the  heart  may 
be  mistaken  for  heart-murmurs.  Those  that  come  from  the  trachea 
and  bronchi  can  easily  be  excluded  by  having  the  patient,  if  necessary, 
hold  the  breath.  But  it  is  more  difficult  to  discriminate  between  heart- 
murmurs  and  those  that  have  their  origin  in  the  aorta  (especially 
aneurism),  regarding  which  see  below. 

Inorganic,  Ancemic  Murmurs.     [Synonyms :  accidental, 
blood  ynurmurs.) 

These  are  so  designated  because  they  occur  in  all  forms  of  ancemia, 
both  light  and  severe,  but  especially  in  chlorosis,  in  all  wasting  dis- 
eases, and  also  in  febrile  diseases,  without  there  being  any  disease  at 
all  of  the  heart  or  vessels.  They  serve  as  a  sign  of  anaemia ;  they 
generally  entirely  disappear  with  the  removal  of  this  condition. 

In  very  pronounced  cases  there  are  very  soft,  systolic,  blowing 
murmurs  which  are  heard  over  the  pulmonary  artery  or  lower  down 
with  indefinite  location,  or  they  may  even  be  heard  over  the  apex. 
But  not  very  infrequently  such  an  inorganic  murmur  is  also  sharp, 
even  very  loud ;  on  the  other  hand,  it  is  very  seldom  diastolic ;  also 
we  may  almost  say  that  it  never  is  heard  over  the  aorta.  Thus  the 
other  signs  of  valvular  disease  are  wanting,  especially  hypertrophy  of 
a  ventricle,  while  the  pulse  gives  evidence  of  anaemia,  and  there  are 
murmurs  in  certain  vessels,  especially  the  veins  of  the  neck. 

Sometimes  there  is  at  the  same  time  considerable  dilatation  of  the 
heart,  as  takes  place  in  anaemia  (which  see)  ;  on  the  other  hand,  we 
have  those  marked   dilatations  which  give    rise    to    murmurs   from 


230  SPECIAL  DIAGNOSIS. 

relative  valvular  insufficiency  and  which  may  also  exist  in  severe  con- 
ditions, with  which  we  are  not  at  present  concerned. 

It  is  very  difficult  to  explain  anaemic  heart-murmurs.  Nothing  of 
what  has  already  been  said  regarding  murmurs  seems  to  us  to  be 
applicable  here ;  we  think  with  others  that  the  nature  of  the  phenom- 
ena differs  in  different  cases,  and  in  many  cases  we  may  apply  Sahli's 
supposition  that  venous  murmurs  from  the  large  veins  in  the  thorax 
lie  behind  these  heart-murmurs. 

For  distinguishing  them  from  the  organic  heart-murmurs  it  is  in 
the  first  place  necessary  to  call  to  mind  what  has  been  mentioned  as 
characteristic  of  ansemic  murmurs,  and  then  to  observe  whether  there 
are  other  signs  of  anaemia  present.  Further,  a  valvular  defect  is  to 
be  excluded  by  the  most  careful  examination  of  the  heart  and  pulse. 
It  is  true  that  in  many  cases  the  phenomena  are  such  that  we  can 
only  obtain  a  clear  idea  by  long  observation,  especially  remarking 
whether  treatment  of  the  aneemia  removes  the  murmur.  It  is  very 
difficult  to  decide  that  a  diastolic  murmur  is  due  to  anaemia. 

The  author  recalls  having  seen  two  cases  of  pronounced  pernicious 
anaemia  complicated  with  mitral  endocarditis  and  mitral  insufficiency, 
in  both  of  which  the  differential  diagnosis  between  anaemic  murmurs 
and  the  valvular  disease  mentioned  could  not  be  positively  established 
during  life.  In  both  there  existed  simultaneously  considerable  emphy- 
sem.a  which  concealed  the  slight  hypertrophy  of  the  left  and  right 
ventricles, 

Pe7'icardial  Murmurs.     \^Friction-sounds^ 

The  name  explains  the  situation  of  these  murmurs.  Their  nature 
is  the  same  as  pleuritic  friction-sounds ;  they  are  caused  by  the  fric- 
tion of  the  visceral  and  parietal  pericardium  made  by  the  action  of 
the  heart  when  their  opposing  surfaces  rub  against  one  another ;  they 
do  this  when  the  surfaces  are  rough,  exceptionally  even  if  they  are 
simply  unusually  dry. 

We  have  near  to  the  ear  a  ringing,  short  scratching,  scraping, 
shuffling,  more  rarely  a  creaking  sound,  one  which  with  a  little  prac- 
tice is  generally  easily  correctly  recognized  by  its  acoustic  character. 
It  is  generally  very  sharply  defined  as  to  location,  and  is  most  fre- 
quently heard  at  the  base  of  the  heart,  but  often  farther  down  at  the 
left  of  the  sternum. 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.       231 

Of  greater  importance  is  the  relation  of  the  friction-sound  to  the 
action  of  the  heart :  it  occurs,  not  in  close  conjunction  with  the  sounds, 
but  between  them,  either  only  during  the  systole,  or  more  frequently 
in  both  stages,  but  generally  louder  with  the  first  sound : 

Fig.  58. 


S  D  S  D  S 

Pericardial  murmurs. 


More  rarely,  tolerably  closely  before  and  after  the  second  sound : 

Fig.  59. 


S  D  S  D  S 


Or  covering  the  first  sound : 


Fig.  60. 


The  rubbing  of  marked  pericardial  friction-sounds  can  be  felt  by 
applying  the  hand  to  the  spot.  Several  special  peculiarities  of  these 
friction-sounds  will  be  mentioned  when  we  treat  of  differential  diagnosis. 

Pericardial  friction-sounds  occur : 

In  Pericarditis,  when  the  surfaces  of  the  pericardium,  where  the 
fibrinous  exudation  exists,  rub  against  each  other  without  becoming 
adherent.  Hence,  we  hear  friction-sounds  in  pericarditis  sicca  so  long 
as  it  is  not  adhesive,  and  in  pericarditis  exudativa,  if  there  is  fibrinous 
exudation  without  enough  fluid  completely  to  separate  the  surfaces  of 
the  pericardium.  This  is  why  the  friction-sound  is  generally  heard 
at  the  base  of  the  heart  or  near  to  it ;  it  is  not  infrequently  heard 


232  SPECIAL  DIAGNOSIS. 

there  as  the  first  sign,  and  then  often  disappears  as  the  exudation 
increases,  and  it  may  again  return  when  the  exudation  diminishes. 
The  disappearance  of  a  previously  existing  pericardial  friction-sound 
may  depend  upon  one  of  four  causes:  1.  The  complete  decline  of  a 
pericarditis,  without  any  sequelpe.  2.  By  the  addition  of  a  fluid 
exudation.  3.  By  adhesion  of  the  pericardial  surfaces.  4.  From 
great  weakness  of  the  heart.  It  is  necessary  to  ascertain  in  every 
case  which  of  these  four  causes  is  operating.  If  there  is  no  evidence 
of  the  second  or  the  fourth,  then  the  first  and  third  must  be  considered ; 
and  between  these  it  is  possible  to  make  a  difierential  diagnosis  only 
in  very  rare  cases. 

They  also  occur  in  rare  cases  of  tuberculosis  of  the  'pericardium 
(which  usually  results  in  adhesion),  quite  exceptionally  with  fragments 
of  fibrinous  cords  and  calcifications  in  the  pericardium,  and  in  abnor- 
mal dryness  of  the  pericardium,  as  in  cholera. 

The  differential  diagnosis  between  pericardial  and  endocardial 
murmurs  is  generally  very  easy  for  those  who  are  accustomed  to  hear 
both  sounds,  frequently  by  the  character  of  the  pericardial  sounds  and 
the  circumstance  that  they  sound  so  near  the  ear.  Musical  persons 
generally  also  immediately  recognize  the  difference  in  time  (see  above). 
But  the  following  may  enable  us  to  distinguish  between  them : 

(a)  Very  much  the  most  important  is  the  consideration  of  the 
whole  picture  of  the  disease  (form  of  the  dulness,  apex-beat,  sounds, 
pulse,  etc.). 

(b)  Change  of  position.  The  pericardial  sound  almost  always 
changes,  and  much  more  than  the  endocardial,  with  change  of 
position. 

(c)  Strong  pressure  with  the  stethoscope.  If  we  press  exactly  at 
the  right  spot,  especially  if  it  be  in  an  intercostal  space,  sometimes 
the  pressure  very  strikingly  increases  a  pericardial  sound,  but  never 
an  endocardial  one.  But  in  the  majority  of  cases,  even  of  the  former, 
the  sounds  are  not  increased  by  pressure ;  hence,  it  is  merely  confirma- 
tory when  it  exists,  but  failure  to  notice  it  has  no  meaning. 

(d)  Pericardial  sounds  often  change  their  location,  strength,  and 
character  in  a  few  hours ;  they  may  even  very  quickly  disappear  and 
very  suddenly  return  (see  above).  Endocardial  murmurs  are  markedly 
chronic  and  regular.     Very  exceptionally  they  come  and  disappear 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.       233 

suddenly,  if  they  are  organic,  and  only  in  exceptional  cases  when  due 
to  heart  weakness. 

Extra-pericardial  friction-sounds.  The  friction- sounds  which  are 
heard  close  to  the  heart,  and  even  over  it,  and  which  resemble  them 
in  sound,  may  be  very  easily  confounded  with  the  pericardial  sounds. 
This  extra-pericardial  sound  is,  in  the  great  majority  of  cases,  a, pleuritic 
friction-sound  which  is  caused  by  the  contact  of  the  pleura  with  the 
heart,  especially  at  the  linguJa,  and  which  by  the  mechanical  effect  of 
the  action  of  the  heart  results  in  thrusts  which  correspond  with  the 
movements  of  the  heart.  It  is  distinguished  from  pericardial  friction- 
sound  in  that  it  is  greatly  influenced  by  the  breathing :  it  is  often 
heard  only  with  deep  inspiration,  or,  on  the  contrary,  during  very 
superficial  breathing.  In  individual  cases  we  hear  it  as  pleuritic 
friction  with  strong  breathing,  while  with  quiet  breathing  it  has  the 
time  of  pericardial  friction-sound. 

There  occurs,  also,  a  peritoneal  friction  with  peritonitis  involving 
the  lower  surface  of  the  diaphragm  (subphrenic  peritonitis),  and  quite 
exceptionally  over  the  liver.  This  sound  is  transmitted  by  the  motion 
of  the  heart  upon  the  diaphragm  as  a  pseudo-pericardial  sound 
(Emminghaus). 

The  differential  diagnosis  of  these  sounds  from  pericarditis  will 
depend  upon  the  other  signs  of  a  pleurisy  or  peritonitis,  and  with 
reference  to  pleuro-pericardial  friction  the  effect  of  the  breathing  is 
to  be  considered.  Hence,  the  differential  diagnosis  may  here  be  very 
difficult,  because  sometimes  a  pleurisy  close  to  the  heart  may  by 
contiguity  awaken  a  pericarditis. 

Mne  crepitations,  like  those  in  emphysema  of  the  skin  (see  p.  55), 
occur  in  the  neighborhood  of  the  heart,  synchronous  with  the  action 
of  the  heart,  in  mediastinal  emphysema. 

Metallic  pericardial  splashing  results  from  fluid  and  air  in  the 
pericardium  (pyo-pneumocardium),  exactly  as  we  have  succussion-sound 
with  hydro-pneumothorax,  only  that  the  succussion  is  caused  by  the 
heart  itself.  Moreover,  after  the  analogy  of  extra-pericai"dial  friction- 
sound,  a  pseudo-pericardial — in  fact,  pleuritic — splashing,  simultaneous 
with  the  motions  of  the  heart,  occurs  with  hydro-pneumothorax,  where 
the  motions  of  the  heart  are  communicated  to  the  fluid.  This  happens 
exceptionally,  too,  with  large  cavities  close  to  the  heart  or  when  the 
stomach- is -filled  with  fluid  and  air.     But.  these  are  merely  curiosities. 


234  SPECIAL  DIAGNOSIS. 

Exploratory  puncture  of  the  heart  is  only  to  be  undertaken  with 
reference  to  the  performance  of  puncture,  and  hence  belongs  under 
therapeutics. 

Examination  of  the  Arteries. 

Usually  we  select  the  radial  pulse,  which,  because  of  its  importance, 
requires  a  separate  and  complete  consideration.  Then  we  can  add  to 
this  the  description  of  the  characters  of  the  other  arteries. 


I.    THE    PULSE,  ITS  PALPATION  AND  GRAPHIC. REPRESENTATION. 

From  the  commencement  of  medical  study  the  radial  artery  has 
been  examined  where  it  passes  between  the  styloid  process  of  the 
radius  and  the  tendons  of  the  long;  flexors  of  the  hand  and  fingers. 
The  examination  of  the  pulse  is  not  a  simple  thing.  It  requires 
practice,  and  hence  it  is  the  more  important,  in  order  to  be  able  to 
recognize  the  differences  and  peculiarities  of  different  cases,  always  to 
take  the  pulse  at  the  same  artery  ;  but  it  is  easy  to  understand  that 
the  radial  artery  is  preferable  because  of  its  location,  and  hence  it  hals 
been  selected. 

Palpation  of  the  Pulse. 

The  arm  being  held  in  an  unconstrained  position,  we  palpate  the 
radial  by  making  slight  pressure  upon  it  with  the  tips  of  the  first 
and  second  fingers.  Generally  the  impression  is  threefold  :  we  learn 
the  condition  of  the  artery  itself,  the  general  state  of  its  fulness  ivith 
blood,  and  its  pulsatory  dilatation  and  contraction.  This  latter  con- 
stitutes the  pulse  in  its  narrow  sense 

We  study  the  pulse  with  reference  to  its  frequency,  its  rhythm 
(whether  the  succession  of  beats  is  regular  or  not),  and  its  quality. 
First  we  consider  the  normal  pulse  ;  then  the  pathological  departures 
from  it  with  reference  to  these  three  points  of  view. 

1.   The  Normal  Pulse. 

Its  frequency  varies  with  the  period  of  life,  being  highest  in  the 
newly  born — about  140  beats  in  the  minute.  It  becomes  constantly 
less  up  to  the  twentieth  year,  when  in  the  adult  male  or  female  it  is, 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.        235 

on  the  average  70  to  75,  and  again  somewhat  rises  with  age  up  to 
about  80  beats.  Sex  makes  a  slight  difference,  the  female  averao^e 
being  a  few  beats  more  than  the  male  at  the  same  age.  Moreover, 
the  size  of  the  body  has  some  influence ;  the  average  of  large  persons 
is  somewhat  less  than  that  of  smaller  persons,  cceteris  paribus. 

The  daily  variations  in  the  frequency  of  the  pulse  correspond  with 
those  of  the  bodily  temperature ;  the  maximum  is  generally  between 
noon  and  evening,  the  minimum  in  the  early  morning ;  the  difference 
is  generally  less  than  ten,  seldom  more  than  twenty  beats.  Of  about 
the  same  value  is  the  variation  of  the  pulse  with  reference  to  the 
position  of  the  body :  its  frequency  is  highest  in  standing,  less  while 
sitting,  and  least  while  lying  down.  It  varies  also  with  the  external 
temperature,  in  case  the  latter  changes  considerably  from  the  average: 
the  lower  the  temperature  the  higher  the  pulse. 

Meals,  especially  of  food  that  is  rich,  and  of  hot  dishes  and  drinks, 
quicken  the  pulse  for  one  or  two  hours.  Sleep  has  no  essential  effect, 
though  the  pulse  rises,  and  generally  considerably  for  a  short  time  at 
the  moment  of  wiaking,  even  when  this  is  without  noticeable  excite- 
ment (see  below). 

Movement  of  the  body  always  increases  the  frequency,  under  some 
circumstances  even  till  the  frequency  is  doubled.  Active  deep  breath- 
ing increases  it.  Mental  excitement  of  any  kind,  as  fright,  anxiety, 
joy,  joyful  or  painful  tension  likewise  quickens  the  pulse,  but  very 
differently  in  amount  in  different  individuals  according  to  their  gen- 
eral excitability. 

All  the  above-mentioned  influences  manifest  themselves  with  very 
marked  variations  according  to  the  bodily  constitution  and  the  char- 
acter of  the  nervous  system  [temperament].  Pale,  delicate  persons, 
who  are  also  excitable,  show  the  greatest  increase  in  frequency. 
During  convalescence  merely  rising  in  bed,  a  little  food,  joyful  or  sad 
news  considerably  quickens  the  pulse.  In  disease  this  is  still  more 
the  case,  of  which  see  below. 

Method  of  observing  the  pulse:  After  excluding  the  temporary 
influences  that  have  been  mentioned,  we  count  by  the  second-hand  of 
the  watch  for  twenty  seconds ;  where  greater  exactness  is  required 
for  a  half  or  full  minute.  Sometimes  in  hospitals  the  nurses  employ 
small  sand-glasses  ;  of  course,  their  accuracy  must  be  carefully  tested. 
[In  England  and  America  these  glasses  are  not  used.]     Sometimes  in 


236  SPECIAL  DIAGNOSIS. 

sickness  the  pulse  is  so  frequent  that  it  cannot  be  counted.  It  has 
been  recommended,  under  these  circumstances,  to  try  to  count  every 
other  beat,  and  then  to  double  the  result.  In  case  the  radial  pulse 
cannot  be  felt,  or  if  we  suspect  that  some  beats  drop  out  (see  under 
Intermittent  Pulse),  we  can  then  count  while  we  auscultate  the  heart. 

In  connection  with  the  employment  of  temperature-charts  we  have 
become  accustomed  to  note  upon  the  chart,  every  time  the  tem. 
perature  is  taken,  also  the  frequency  of  the  pulse  and  respiration ; 
thus  we  obtain  upon  the  fever-chart  a  continuous  line  representing 
the  pulse,  which  materially  aids  in  forming  a  judgment  of  it.  (Re- 
garding the  value  of  this  continued  observation  of  the  pulse,  see 
below.) 

The  rhythm  of  the  pulse  in  perfect  mental  quiet  and  during  quiet 
breathing  is  in  health  regular.  But  mental  excitement  easily  makes 
the  pulse  somewhat  irregular,  especially  in  nervous  persons.  Again, 
the  rhythm  of  the  pulse  is  changed  with  many  persons  during  deep 
breathing,  especially,  too,  in  nervous  persons.  Usually  at  the  end  of 
expiration  and  the  beginning  of  inspiration  it  is  quicker,  while  at  the 
height  of  inspiration  and  the  beginning  of  expiration  it  is  slower. 

Normally  the  pulse  at  the  two  radials  is  exactly  simultaneous,  the 
crural  pulse  is  also  approximatively  simultaneous  with  the  radial. 
But  if  we  compare  the  radial  with  the  action  of  the  heart  we  notice 
that  it  is  always  notably  later  than  the  corresponding  systole. 

Regarding  the  quality  of  the  pulse :  the  radial  in  health  has  a  cer- 
tain general  fulness  and  hardness,  and  the  separate  pulse- waves  also 
have  a  certain  size,  hardness,  and  form,  All  these  peculiarities  ex- 
hibit not  inconsiderable  variations  within  the  normal.  Correct  esti- 
mate of  them  by  palpation  is  a  matter  of  much  careful  practice.  (For 
particulars  regarding  the  diiferent  forms  of  pulse  which  we  meet,  see 
below.)  Here  it  is  next  to  be  remarked  that  in  the  normal  pulse 
equality  of  its  separate  beats  is  desirable  [equal  pulse) ;  only  quite 
small,  scarcely  perceptible  inequality  sometimes  occurs,  again  especi- 
ally with  nervous  persons.  A  general  symmetrical  increase  in  the 
hardness  of  the  pulse  and  enlargement  of  its  waves  are  results  of  phys- 
ical exertion,  mental  excitement,  etc.;  in  short,  from  anything  that 
temporarily  quickens  the  action  of  the  heart. 


EX  A  MINA  TION  OF  THE  CIR  CULA  TOR  Y  A  PPA  RA  TVS.       2  SI 

2.  Pathological  Frequency  of  the  Pulse. 

We  distinguish  a  pulsus  varus  (slow,  infrequent  pulse)  and  a  fre- 
quent pulse  (accelerated  pulse). 
The  sloiv  ijulse  occurs  : 

1.  In  individual  cases  of  pathological  increase  of  the  work  of  the 
heart,  namely,  in  acute  nephritis^  especially  the  nephritis  of  scarlet 
fever.  Hypertrophy  of  the  left  ventricle  is  often  included  here.  But 
the  diminished  frequency  of  the  pulse  is  very  slight. 

2.  In  the  opposite  condition  of  diminished  pressure  in  the  arterial 
system  in  consequence  of  hemorrhage ;  and  in  individual  cases  of 
febrile  diseases  with  fatal  collapse. 

3.  In  disease  of  the  heart-muscle,  especially  in  fatty  heart,  hut 
also  in  fibroid  myocarditis  (but  here  w^e  must  be  on  our  guard  not  to 
confound  it  with  intermittent  pulse,  which  see) ;  48  to  36  beats  are 
here  not  at  all  infrequently  met  with.  The  lowest  number  pretended 
to  have  been  observed  is  8. 

4.  In  old  age,  without  any  disease  of  the  heart  (this  is  very  excep- 
tional, but  yet  it  sometimes  occurs,  as  I  have  been  able  in  one  case  to 
confirm  by  autopsy  that  there  was  no  disease),  and  in  marked  iyiani- 
tion  (from  stenosis  of  oesophagus,  pylorus,  etc.).  Hei'e,  also,  the 
slowing  of  the  pulse  may  be  considerable — even  to  48  or  less. 

5.  Sometimes  with  stenosis  osfii  aortce;  here  the  diiference  is  very 
slight — about  60  beats. 

6.  In  disease  of  the  brain  or  of  the  meninges,  which  results  in 
irritation  of  the  vagus  centre.  This  may  really  be  only  mechanical, 
from  increased  intracranial  pressure  (tumors,  hemorrhages,  hydro- 
cephalus), or  from  inflammatory  irritation  [acute  meningitis,  especially 
basilar).     The  slowing  is  considerable. 

7.  In  the  critical  decline  of  fever  in  acute  febrile  diseases,  possibly 
from  the  effect  of  certain  products  of  the  fever  upon  the  heart  or  the 
vagus  centre,  an  effect  which  is  only  manifest  when  the  quickening 
effect  of  the  high  temperature  (which  see)  upon  the  pulse  is  past.  It 
is  a  considerable,  but  quite  temporary  slowing. 

8.  In  hepatogenic  icterus,  from  the  effect  upon  the  heart  of  the  gall- 
acids  circulating  in  the  blood.  The  pulse  is  diminished  quite 
frequently  as  low  as  to  48,  sometimes  still  lower. 

9.  In  individual  cases,  with  acute  articular  rheumatism. 


238 


SPECIAL  DIAGNOSIS. 


It  has  been  recently  stated  that  slowness  of  the  pulse  ("  brachy- 
cardia ' ')  in  many  of  these  cases  is  accompanied  with  characteristic 
maladies  (attacks  of  fainting,  a  feeling  of  oppression  of  breathing, 
apoplectiform  attacks).  It  has  also  been  observed  as  a  seemingly 
independent  condition  without  any  sign  whatever  of  an  anatomical 
disease,  hence  as  a  "neurosis"  (G-rob).  We  have  never  seen  any 
cases  of  this  kind. 

Frequent  pulse  occurs : 

1.  In  fever,  as  its  chief  manifestation.  We  recognize  a  general 
relation  between  the  elevation  of  the  temperature  and  quickening  of 


Fig.  61. 


Fig.  62. 


P.    T. 

180    41° 


160    40 


140    39 


120    38 


80    86 


■■■ni 

BBIlll 
■fill 

■11H1II 
■■IBM 

liwnaii 

UBWHII 

■■■ir 

■■HIBII 
■■HIBII 

■■HHir 

■■■■II 


!BI 


■■■■■B 

■■■■■■ 


iffii 


la 

MMIBHHHgB 

■■nnniiiHHHg 

■»{■■■■ 

■ill 


mil 
1*11 


■■■iin 


160    40° 


140    39 


120    38 


100    37 


S^ii 


svani&inBwiiHHHHH^ 

~     WMIHHfililHAWIlHgHHi 

^■■■■niKaBriiHSHg 

■■■MIVAVJBMfaSS^H 

MMtaBSSIMga 

(■■aHBHHHMgM|lliBBI_ 
WSSSSSBSSSSM 
wasMsaassah 

|B»B8BraSIBSBB 

■■■■■■■■!■■■■■■■ 


Diminution  of  frequency  of  pulse 
after  critical  fall  of  temperature  in 
pneumonia.  The  unbroken  line 
represents  the  temperature-curve, 
the  broken  one  the  pulse-curve. 


Abdominal  typhus  in  the  third  to  the  fourth 
week.  The  rise  in  the  pulse  corresponds  with 
the  beginning  of  pneumonia. 


the  pulse — to  every  degree  of  heat  above  37°  the  pulse  increases  8 
beats  above  the  normal  (Liebermeister) ;  but  there  are  very  great 
variations  from  this  proportion,  according  to  the  kind  of  febrile  disease, 
its  localization  in  particular  organs,  and,  further,  with  the  age  of  the 
patient,  the  strength  of  the  heart.  Thus,  in  abdominal  typhus,  so 
long  as  it  is  not  complicated,  there  is  only  a  moderate  quickening  of 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS. 


239 


the  pulse ;  hence,  in  this  disease,  a  pulse  of  120  has  a  graver  meaning 
than,  for  example,  it  has  in  pneumonia.  This  moderate  quickening 
of  the  pulse,  peculiar  to  typhus  abdominalis,  is  even  an  aid  in 
diagnosis  in  severe  cases,  as  distinguishing  it  from  acute  miliary 
tuberculosis  and  pyoemia.  It  has  already  been  mentioned  that  in 
meningitis  there  is  slowing  of  the  pulse;  when  meningitis  is  added  to 
a  febrile  disease  it  may  lower  the  pulse,  previously  quickened,  to  the 
normal,  or  may  even  bring  it  below  the  normal.  On  the  other  hand, 
during  an  abdominal  typhus,  the  addition  of  a  com'^Wcoimg pneumonia 
will,  under  some  circumstances,  be  first  noticed  by  the  increased 
frequency  of  the  pulse.     (See  Fig.  62.) 


Fig.  63. 


Fig.  64. 


200    42° 


180    41 


160    40 


140    39 


120    38 


100    37 


80    36 


■■■■■■■■ 

iiii 


Ear . 

Eiragga 

■■)■■■■■ 

■■■■■■■H 

_■■■«■■■■ 
■■■(■■■■■B 

■■■■■■■■H 

■■■IIIIHHHH 

BBHMIBBHH 
■HiiinHSg 

mmmmkxmmm 

^aiHBB 


■■!»»■■■ 
■HViMflHB 

BHilill911B!~ 

■■HHHBBBL 

^■■■■■Hg 
_9iBBHggB 
wmmmmmmr 


Very  rapid  action  of  the  heart 
(mitral  insufiSciency). 


140    39 


120    38 


100    37 


80    36 


Very  rapid  action  of  the  heart 
(convalescence  from  typhus;  sus- 
picion of  mitral  insufficiency). 


Febrile  diseases  with  complicating  heart  disease  usually  have  a 
■quicker  pulse  than  the  same  diseases  when  the  heart  is  normal.  With 
children  the  pulse  is  always  very  much  higher  in  febrile  diseases  than 
with  adults. 

In  the  course  of  febrile  diseases  the  constant  observation  of  the 


240 


SPECIAL  DIAGNOSIS. 


frequency  of  the  pulse  is  of  the  greatest  importance  for  estimating  the 
strength  of  the  heart,  and  with  it  the  general  vigor,  or  showing  the 
occurrence  of  complications,  etc.  (See  further,  hereafter.)  It  is  also 
to  be  observed  that  in  fever  the  frequency  of  the  pulse  is  immediately 
increased  by  the  least  exertion  or  by  excitement. 

In  general  it  is  an  unfavorable  sign  when  adults  have  a  pulse  of 
over  120,  and  the  case  requires  special  consideration.  But  when  it 
reaches  140  it  is  a  grave  symptom. 

2.  In  valvular  disease  of  the  hearty  except  only  in  stenosis  of  the 
aorta  (see  above),  and  also  even  with  complete  compensation.  Attacks 
of  great  frequency  of  the  pulse — 180  and  over — are  infrequent  occur- 
rences, which  chiefly  accompany  mitral  defects  {'palpitation  of  the 
heart). 

Fig. 


65. 


P.    T. 


160    40° 


140    39 


120    38 


100    37 


80     36 


■■■■■■■ 

■■■■■■■■■■■■BB 

SBSSKaKIII 


SHHEBaniMH 

■■■■■■■nHiinflB 

isaa 


■■■nHRiHKIII 


■"■n 


ESBBBSIISIISiiB 


Increased  frequency  of  the  pulse  in  fatal  collapse  (erysipelas). 

3.  In  heartfailure  or  paralysis.  Thus,  in  the  collapse  of  febrile 
diseases  (see  Fig  65),  where  there  is  a  simultaneous  fall  of  the 
temperature  and  rise  of  the  pulse ;  in  the  arrested  compensation  of 
heart  disease,  and  in  weakening  of  the  heart  in  consequence  of  disease 
of  the  substance  of  the  heart;  finally,  with  central  and  peripheral 
paralysis  of  the  vagus. 

4.  In  certain  neuroses :  Basedow's  disease,  nervous  palpitation, 
angina  pectoris  (without  the  nature  of  this  phenomenon  being  clear). 

5.  In  any  condition  of  anxiety,  and  with  severe  pain. 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.        241 

3.    Want  of  Rhythm  of  the  Pulse. 

Instead  of  the  normal  equal  succession  of  the  beats  there  may  be 
complete  irregularity  {arhythn) ;  in  the  most  marked  degree  this  is  so 
in  mitral  stenosis  (even  when  there  is  perfect  compensation).  Moderate 
or  marked  arhythm  is  very  frequent  in  myoearditis  (sometimes  the 
inequality  of  the  pulse  is  here  the  only  sign).  It  occurs  during  the 
stage  of  incompensation  in,  all  cases  of  heart-defect,  and  sometimes  in 
all  forms  of  marked  heart- weakness.  Moreover,  the  inequality  of  the 
pulse  [irregularity  of  volume]  is  more  important  in  judging  of  the 
weakness  of  the  heart  than  arhythm. 

If,  in  such  arhythm,  there  are  individual  pauses  in  which  no  pulse 
is  felt,  then  we  speak  of  "suspended"  pulse,  which  may  be  pulsus 
deficiens — that  is,  the  pauses  indicate  real  pauses  in  the  action  of  the 
heart ;  or  it  may  be  a  pulsus  intermittens  :  they  result  from  weak 
contractions  of  the  heart,  which  cannot  be  felt  as  far  as  the  radial. 
We  determine,  in  a  given  case,  which  of  the  two  kinds  of  pulse  it  is 
by  auscultating  the  heart. 

But  there  are  other  forms  of  irregularity  of  pulse  in  which  the 
irregularity  of  the  beats  follows  a  rule:  pulsus  higeminus,  p. 
trigeminus  (where  two  or  three  beats  are  regular  and  then  follows  a 
longer  pause).  These  forms  generally  indicate  moderate  weakness  of 
the  heart. 

Lastly,  we  must  mention  an  especially  frequent  form  of  irregularity 
which  stands  somewhat  between  the  two  last-named  forms  and  com- 
plete irregularity — the  pulsus  inter cidens :  after  several  perfectly 
regular  beats,  suddenly  there  is  one  that  follows  immediately  after 
the  last  regular  one  (which  is  also  always  weaker),  then  there  generally 
follows  a  slight  pause.  Most  frequently  it  indicates  considerable 
weakness  of  heart,  and  is  often  the  forerunner  of  severe  heart-weak- 
ness.    It  occurs  in  valvular  disease  and  myocarditis. 

In  order  to  determine  the  succession  of  pulse-beats  it  is  sometimes 
useful  to  employ  the  graphic  method  (which  see). 

4.    Quality  of  the  Pulse. 

As  has  been  already  mentioned  above,  a  correct  judgment  of  the 
size  and  tension  of  the  radial  artery  and  of  the  size  and  form  cf  the 

16 


242  SPECIAL  DIAGNOSIS. 

in<iividual  waves  can  only  be  attained  by  much  practice.  It  is  indis- 
pensably necessary  that  there  should  be  acuteness  of  feeling  in  the 
examining  finger,  much  experience  of  what  is  normal  and  what  is 
pathological,  and  of  the  boundaries  between  the  two,  which  cannot  be 
sharply  defined  in  words. 

The  inequality  of  the  examination  must  be  taken  into  consideration, 
as  it  is  affected  by  somewhat  individual  diff"erences  of  the  location  of 
the  arteries,  the  difference  in  the  subcutaneous  fat,  or  as  affected  by 
arterial  sclerosis.  The  exact  examination  of  the  pulse  may  not  be 
possible  on  account  of  the  abnormal  course  of  the  radial  artery — the 
most  frequent  variation  being  where  the  artery  winds  around  the  radius 
to  its  dorsal  surface  above  the  styloid  process. 

We  distinguish  the  different  forms  of  pulse  according  to  the  follow- 
ing points  of  view : 

1.  According  to  the  size  of  the  pulse:  full  or  empty  pulse,  pulsus 
plenus — vacuus;  a  not  very  clear  method  of  designation.  It  would 
be  much  more  suitable  to  describe  the  average  fulness  of  the  artery, 
or,  still  better,  its  thickness  at  the  moment  of  its  systole — that  is,  in 
the  depression  between  two  pulse-waves.  In  this  sense  the  pulse  is 
full  in  almost  all  those  cases  in  which  it  is  large  in  so  far  as  it  depends 
upon  work  of  the  heart,  which  is  strong  or  increased.  But  it  further 
depends,  to  a  certain  extent,  upon  the  amount  of  blood  in  the  system ; 
a  certain  fulness  of  the  pulse,  which,  in  a  strong  person,  is  not  remark- 
able, in  an  anaemic  subject  indicates  a  pathological  increase  in  the 
work  of  the  heart.  Within  certain  limits,  moreover,  the  difference  in 
the  fulness  of  the  pulse  is  individual,  being  simply  dependent  upon 
the  internal  diameter  of  the  arteries.  We  are  not  to  confound  a  full 
pulse  with  a  case  where  there  is  thickening  of  the  wall  of  the  artery 
by  arterial  sclerosis. 

Larger  and  small  pulse  :  pulsus  magnus — parvus.  When  the  work 
of  the  heart  is  simply  increased,  and  still  more  when  there  is  hyper- 
trophy of  the  left  ventricle,  the  pulse  is  large.  There  is  an  exception 
to  this  when  we  have  the  two  valvular  defects,  in  which  the  left  ven- 
tricle, notwithstanding  its  hypertrophy,  is  able  to  force  only  a  mod- 
erate quantity  of  blood  into  the  aorta  (aortic  stenosis,  see  under  pulsus 
tardus),  and  mitral  insufficiency.  The  reason  for  the  former  is  clear ; 
the  explanation  of  the  latter  is,  that  with  every  systole  a  part  of  the 
blood  contained  in  the  left  ventricle  flows  back  into  the  left  auricle. 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.        243 

Absence  of  pulse  depends  upon  diminished  work  of  the  heart,  upon 
an  obstruction  between  the  heart  and  the  aortic  system  (aortic  steno- 
sis, aneurism),  and  upon  marked  anaemia.  It  is  present  in  the  highest 
degree  in  mitral  stenosis,  since  in  this  condition  the  left  ventricle  con- 
tains an  abnormally  small  quantity  of  blood,  and  hence  it  can  drive 
but  little  into  the  aorta. 

If  the  pulse  is  very  small,  and  at  the  same  time  very  empty,  it  is 
called  thread-like  or  filiform.  The  trembling  pulse  [pulsus  tremulus) 
is  caused  by  a  moderately  full  artery,  in  which  the  wave  is  impercept- 
ibly small.     Both  are  noticed  when  the  heart  is  very  weak. 

Regular  and  irregular  pulse  [as  to  volume]  :  pulsus  cequalis — in- 
cequalis.  As  was  previously  stated,  there  occur  in  health  insignificant 
irregularities  in  the  individual  pulse- waves.  A  very  marked  inequality 
is  a  most  important  sign  of  weak  heart,  more  important  than  the 
irregularity  which  almost  always  accompanies  it.  Only  in  mitral  ste- 
nosis we  have  a  very  markedly  unequal  (and  irregular)  pulse  without 
the  heart  being  really  weak. 

Often,  too,  there  exists  in  a  measure  a  condition  between  inequality 
and  irregularity  as  follows  :  A  pulse  follows  the  previous  one  with  a 
shorter  pause,  then  after  a  longer  pause  there  is  one  with  a  stronger 
beat.  Especially  m  pulsus  intercidens  (see  p.  241)  the  between-beat 
that  immediately  follows  a  pulse-wave  is  always  small. 

Pulsus  alternans  is  so  called  when  a  larger  wave  alternates  with  a 
smaller  one.  At  the  same  time  it  is  generally  bigeminus.  (See 
above.) 

We  call  a  pulse  pulsus  paradoxus  which  has  the  peculiarity  that  in 
deep  breathing,  toward  the  end  of  inspiration,  it  becomes  weaker,  or  is 
once  or  more  times  omitted.  It  is  an  important  sign  o^ pericarditis 
adh<xsiva  with  fibroid  mediastino-pericarditis,  and  it  arises  from  the 
bending  or  traction  of  large  arterial  branches  as  the  thorax  is 
broadened  in  the  act  of  inspiration  and  the  diaphragm  is  pressed 
down. 

2.  We  distinguish  the  form  of  the  pulse- wave  as  quick  or  slow, 
pulsus  celer — tardus.     Here  also  belongs  the  pulsus  dicrotus. 

In  the  quick  pulse  the  artery  quickly  enlarges  and  immediately 
becomes  narrow  with  a  like  quick  contraction.  But  with  a  slow  pulse 
the  enlargement  and  contraction  are  slower  than  normal,  and  the  artery 
also  lingers  in  the  diastole  during  a  portion  of  time  which  a  trained 


244  SPECIAL  DIAGNOSIS. 

finger  may  recognize.  With  the  quick  pulse  the  examiner  notices 
that  the  stroke  is  very  short,  while  in  the  latter  it  is  more  a  pressure 
in  the  vessel  against  the  palpating  finger. 

Every  pulsus  magnus  may  exhibit  a  moderate  celerity.  Only  in 
aortic  insufficiency  is  the  pulse  decidedly  quick.  It  is  a  miniature 
picture  of  the  large  fluctuations  of  pressure  in  the  aorta  which  quickly 
follow  one  another,  as  with  every  systole  it  receives  from  the  dilated 
and  hypertrophied  left  ventricle  an  abnormally  large  quantity  of  blood 
which  it  immediately  disposes  of  in  two  directions — sending  part  back 
again  into  the  ventricle,  and  part  forward  into  the  body. 

It  is  remarkable  that  also  in  heart-weakness  there  is  sometimes  a 
light,  quick  pulse.  It  is  true  that  it  is  always  very  easy  to  compress 
it,  and  between  the  pulse-waves  the  walls  of  the  artery  fall  together 
very  decidedly  {pulsus  vacuus,  and  at  the  same  time  celer). 

Pulsus  tardus  is  an  especial  peculiarity  of  aortic  stenosis,  and  at 
the  same  time  it  is  generally  smaller  than  normal.  How  much  it  may 
be  diminished  in  size  depends  upon  the  degree  of  stenosis  and  the 
strength  of  the  heart.  Pulsus  tardus  occurs  also  with  arterial  scle- 
rosis, likewise  with  lead  colic,  but  also  sometimes  with  other  colics  as 
well  as  in  peritonitis. 

Pulsus  dicrotus  ^y\\\  be  more  exactly  described  with  the  sphygmog- 
raphy  of  the  pulse  (see  p.  248). 

3.  According  to  the  hardyiess  of  the  pulse  (tension  of  the  arterial 
wall)  we  distinguish  hard  or  tense,  and  soft  pulse,  pulsus  durus  {ten- 
sus) — mollis.  Here  we  must  especially  guard  against  confounding  it 
with  arterial  sclerosis,  which  imparts  to  the  wall  of  the  vessel  a  hard- 
ness which  has  nothing  to  do  with  its  tension. 

We  test  the  hardness  of  the  pulse  by  endeavoring  to  compress  it 
with  the  finger ;  it  is  easy  to  compress  a  soft  pulse. 

Again,  it  is  really  the  power  of  the  heart  that  produces  these  pecu- 
liarities, as  well  as  the  active  tension  of  the  wall  of  the  vessel.  In 
heart- weakness  the  small  pulse  is  also  always  a  soft  pulse;  the  large 
pulse  is  likewise  often  hard.  With  pulsus  tardus  there  is  almost 
always  a  strong  action  of  the  heart,  and  if  the  heart  is  hypertrophied 
the  pulse  at  the  same  time  is  often  hard.  When  the  pulse  is  quick 
there  are  constantly  marked  variations  in  its  hardness. 

The  hardness  of  the  pulse  is  especially  characteristic  in  contracted 
kidney  with  hypertrophy  of  the  heart,  also  in  lead  colic  ("  wire  pulse"). 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.        245 

The  pulse  is  tense  also  in  apoplnxy  cerebri  and  in  commencing  menin- 
gitis, no  doubt  from  irritation  of  the  vasomotor  centre. 

V.  Basch  has  constructed  a  sphygmomanometer,  which  is  very  use- 
ful for  measuring  exactly  the  tension  in  the  arterial  wall,  and  thus  the 
blood-pressure.  Unfortunately,  we  cannot  affirm  that  the  absolute 
height  of  the  blood-pressure  in  its  finer  gradations  leads  to  results  that 
have  diagnostic  value.  The  reason  of  this  is  that,  as  v.  Basch  himself 
found,  the  limits  of  the  normal  are  very  wide  apart ;  moreover,  from 
the  fact  that  the  arterial  pressure  is  the  result  of  two  forces  acting  in 
opposition,  the  contraction  of  the  heart  and  the  active  contraction  of 
the  vessel.  Lastly,  as  has  already  been  intimated,  the  anatomical 
peculiarity  of  the  arteries  (arterial  sclerosis)  has  an  influence  upon  the 
hardness — that  is,  the  compressibility  of  the  pulse.  Yet,  after  all,  we 
think  that  v.  Basch 's  instrument  is  very  excellent  for  determining  the 
variations  of  the  blood-pressure  in  the  course  of  making  observations 
upon  a  patient. 

5.  Symmetry  of  the  Radial  Pulse. 

As  has  been  already  mentioned,  apart  from  anatomical  variations 
of  the  artery  upon  one  side,  the  pulse  upon  the  two  sides  is  perfectly 
alike  as  to  time  and  quality.  It  may  be  disturbed,  even  to  complete 
absence  of  the  pulse  upon  one  side. 

1.  By  surgical  diseases  of  the  arm,  as  fracture  of  the  bone,  injuries 
or  operations  which  displace  the  radial,  or  which  result  in  narrowing, 
compression,  or  cicatricial  contraction  of  the  radial,  brachial,  or 
axillary  artery ;  in  which  case  the  pulse  upon  that  side  is  found  to  be 
smaller. 

2.  By  tumors  of  the  chest  cavity,  of  the  supra-  or  infra-clavicular 
fossa,  or  of  the  axilla,  which  press  upon  the  innominate,  subclavian,  or 
axillary  artery  of  one  side.  They  weaken  the  radial  pulse  even  to 
complete  obliteration. 

3.  By  aneurism  of  the  aorta,  innominate  (in  what  way,  see  below), 
also  by  aneurism  of  the  subclavian,  axillary,  and  brachial  (all  very 
rare ;  see  works  upon  surgery). 

4.  By  emboli  and  autocthonous  clots  toward  the  centre  from  the 
location  of  the  pulse.  In  this  case  the  pulse  is  commonly  entirely 
wanting. 

5.  In  pneumothorax,   also   large   pleuritic  exudation  with    com- 


246  SPECIAL  DIAGNOSIS. 

pression  and  distortion  of  the  subclavian.  Sometimes  the  pulse  upon 
the  affected  side  is  smaller,  also  frequently  later. 

Sphygmography  of  the  Radial  Pulse. — K.  Vierordt  originated 
the  idea  of  sphygmography.  With  continued  improvements  of  the 
apparatus  the  idea  has  been  further  developed  by  Marey,  ^olff, 
Landois,  Soinmerhrodt,  Riegel  [and  others]. 

Sommerbrodt's  sphygmograph  is  the  one  now  most  generally  used, 
but  it  has  defects.  Recently  Ludwig  has  very  decidedly  improved 
upon  Marey's  instrument,  as  it  seems  to  me.  It  can  be  obtained 
from  Petzold,  instrument-maker,  in  Leipzig.  [The  instrument  devised 
by  Dr.  Richardson,  of  London,  is,  in  the  opinion  of  the  Translator,  the 
most  practically  useful  one  yet  brought  out.] 

The  sphygmograph  has  little  value  for  the  purposes  of  diagnosis, 
but  is  of  great  value  in  clinical  instruction. 

In  health  the  pulse-curve  obtained  with  this  instrument  shows 
elevations  and  depressions,  ascending  and  descending  line  correspond- 
ing with  the  expansion  and  collapse  of  the  artery.  The  expressions 
"apex  curve"  (c  g)  and  "  curve  at  the  base  "  (b)  do  not  need  further 
explanation.  At  both  these  points  the  curve  stops  only  a  very  small 
portion  of  time. 

The  ascension  line  (a  1)  is  even  almost  perpendicular ;  that  is,  the 
rise  follows  very  quickly.  The  descent  (d)  is  more  drawn  out  and 
shows  several  small  waves,  which  generally  (not  always)  may  be 
distinguished  as  a  marked  elevation  (r),  the  backward-stroke  elevation, 
caused  by  a  wave  of  blood  which  results  from  the  closure  of  the  semi- 
lunar valve,  and  two  (sometimes  also  three)  or  only  one  weaker, 
elevation  produced  by  elasticity  (e) ;  the  elastic  secondary  oscillation 
of  the  wall  of  the  artery  (according  to  Landois,  but  otherwise 
explained  by  others). 

The  elevation  (r),  the  "recoil,"  has  hitherto  been  regarded  as  a 
positive  centrifugal  wave  due  to  the  closure  of  the  aortic  valves. 
But  recent  investigations  have  shown  that  this  positive  wave  is  cen- 
tripetal, and  that  it  is  probably  to  be  regarded  as  a  reflected  wave 
from  the  peripheral  end  of  the  circulation  of  the  body,  as  from  the 
end  of  a  closed  tube  (v.  Frey  and  Krehl).  The  opinion  formerly 
expressed  that  r  was  more  marked  the  nearer  we  were  to  the  heart, 
by  the  new  theory  would  be  explained  by  saying  that  it  was  the  sum- 
mation of  the  reflected  waves  arising  from  the  various  arterial  regions. 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.        247 

It  is  worthy  of  notice  with  regard  to  the  backward-stroke  elevation 
that  it  increases  with  the  diminution  of  the  tension  of  the  artery. 
Thus  it  is  a  sort  of  indication  of  the  blood-pressure.  But  the  eleva- 
tion produced  by  elasticity  is  j  ust  the  opposite.     It  is  to  be  remarked 

Fig.  66. 


Normal  pulse-curve  in  a  healthy  man,  aged  twenty-five  years.    (After  Eichhorst.) 

regarding  the  sphygmography  of  other  arteries  that  r  becomes  more 
marked  the  nearer  we  go  to  the  heart. 

The  following  are  the  essential  pathological  forms  of  sphygmo- 
graphic  pulse- waves  : 

1.  A  descending  line  with  several  very  marked  elasticity  elevations, 
but  smaller  backward-stroke  elevations  (often  difficult  to  make  out) 
which  correspond  with  the  increased  tension  in  the  aortic  system 
{lead  colic,  contracted  kidney  and  acute  nephritis,  etc.). 

Fig.  67. 


2.  On  the  other  hand,  diminution  of  the  elasticity  elevation  with 
more  marked  backward-stroke  elevation  shows  diminished  blood- 
pressure.  Such  increase  of  r  is  called  '^dicrotic,"  and  the  pulse 
''dicrotic  pulse."  Such  a  pulse,  even  if  it  is  only  moderately  pro- 
nounced, can  be  recognized  by  palpation.  It  occurs  in  certain  condi- 
tions which  accompany  a  moderate  diminution  of  strength  of  the 
heart,  but  especially  a  diminution  of  the  tone  of  the  arteries : 

a.  In  acute  febrile  diseases,  and  indeed  in  so  marked  a  degree  and 
so  early  in  typhus  ahdominalis  that  in  diagnosis  we  may  attach  some, 
though  small,  value  to  this  symptom. 


248  SPECIAL  DIAGNOSIS. 

h.  In  chrome  ivasting  diseases,  especially  febrile,  more  than  others 
in  tuberculosis.  Here,  according  to  mj  observation,  it  is  not  infre- 
quent. 

c.  In  other  weak  conditions,  as  after  great  loss  of  blood,  and  in 
general  in  all  forms  of  anaemia. 

Fig.  68. 


Different  forms  of  dicrotic  pulse.     (After  Eichhoest.) 

The  above  curves  show  that  in  the  dicrotic  pulse  the  backward-stroke 
elevation  may  fall  in  the  descending  line  {suh-dicrotie  'pulse).)  as  well 
as  in  the  middle  of  the  basis  curve  {complete  dicrotic  pulse).,  likewise 
in  the  ascending  line  of  the  next  following  wave  {super-dicrotie  pulse). 
The  so-called  monocrotic  pulse  (no  visible  backward- stroke  elevation) 
is  a  sort  of  super-dicrotic  pulse 

What  has  been  said  in  general  regarding  dicrotic  pulse  expresses 
the  diagnostic  value  of  all  these  forms  of  pulse. 

3.  To  the  pulsus  celer  corresponds  a  curve  with  a  very  steep 
ascending  line  and  an  unnaturally  high  apex-curve  (in  consequence  of 
the  quickness  of  the  arterial  diastole  the  recording  lever  of  the  appa- 
ratus is  always  thrown  too  high  up).     Moreover,  the  apex-curve  is 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.        249 

sharp-pointed,  and  the  descending  line  is  almost  as  steep  as  the 
ascending  line.  The  elasticity  elevations  are  marked.  With  pulsus 
celer  due  to  arotic  insufficiency  there  is,  of  course,  no  backward-stroke 
elevation,  as  the  semilunar  valve  does  not  close.  Compare  what  has 
been  said  on  p.  243  upon  Pulsus  celer. 

Fig.  69. 


Pulse-curve  in  aortic  insufficiency.     (After  Struempf.ll.) 

4.  Pulsus  tardus,  as  in  palpation  (see  p.  244)  so  in  the  curve,  is  the 
exact  opposite  of  the  preceding.  With  it  there  are  usually  more  com- 
plete loss  of  the  elasticity  elevation  and  indistinct  backward-stroke 
elevation. 

Fig.  70. 


Pulse-curve  in  stenosis  of  the  aortic  orifice.     (Ibid.) 
Fig.  71. 


Pulsus  tardus  in  atheroma  of  the  arteries.     (After  Eichhorst.) 

A  peculiar  combination  of  pulsus  celer  and  tardus  manifests  itself 
with  insufficiency  and  stenosis  of  the  aorta. 


250 


SPECIAL  DIAGNOSIS. 

Fig.  72. 


Pulse  with  anacrotic  elevation  in  aortic  insufficiency  with  moderate  stenosis  of  the 
orifice  and  arterial  sclerosis. 

In  pulsus  tardus  the  quickness  of  the  apparatus  is  completely 
wanting  on  account  of  the  slowness  of  the  ascension,  hence  it  always 
seems  small  in  comparison  with  the  normal  pulse- wave ;  and  with  that 
of  pulsus  celer  (see  above)  still  smaller  than  is  really  the  case. 

It  is  quite  impossible  to  form  an  estimate  of  the  size  of  the  pulse 
from  the  sphygmographic  curve.  The  unequal  pulse  will  generally 
be  very  beautifully  delineated  by  the  apparatus,  but  it  cannot  be  more 
exactly  depicted  than  it  can  be  learned  by  exact  palpation.  It  is  true 
that  the  apparatus  includes  small  waves  that  the  finger  cannot  recog- 
nize, but  often  these  cannot  be  distinguished  from  the  elevations 
indicating  the  backward  stroke. 


Fig.  7.3. 


Pulse-curve  with  marked  mitral  stenosis.     (After  Steuempell.) 

The  rhythm  of  the  pulse  will,  of  course,  even  if  only  for  a  very 
short  distance,  be  very  well  exhibited,  and  it  is  in  this  direction  that 
the  graphic  delineation  is  very  useful  in  giving  instruction.  But 
here  sphygmography  is  wholly  Avanting  for  diagnostic  purposes,  since 
every  notable  useful  irregularity  can  be  felt  just  as  well. 

Annexed  is  an  example  of  pulsus  bigeminus  (after  Riegel). 

Fig.  74. 


Pulsus  bigeminus.     (After  Riegel.) 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.        251 

Diagnostic  Value  of  the  Examination  of  the  Pulse. — From 
what  has  been  said  it  is  sufficiently  evident  that  for  the  purposes 
of  diagnosis  palpation  of  the  radial  pulse  is  preferable  to  sphyg- 
mography.  The  latter  is  more  circumstantial,  and  gives,  at  best,  to 
one  sufficiently  practised  in  palpation  in  general,  no  better  result 
than  that  it  occasionally  shows  a  dicrotic  pulse  which  the  sense  of 
touch  does  not  detect.  It  very  easily  even  deceives,  especially  regard- 
ing the  size  of  the  pulse,  but  sometimes  also  its  form,  from  reasons  that 
lie  in  the  apparatus.  The  great  value  of  the  sphygmograph  for  the 
clinician  consists  almost  exclusively  in  its  usefulness  in  giving  instruc- 
tion, for  exhibiting  a  characteristic  anomaly  of  the  pulse  to  a  large 
number  of  hearers,  or  it  may  serve  to  show  a  pupil  what  he  ought  to 
feel. 

In  what  follows  will  be  briefly  indicated  in  which  direction  the 
examination  of  the  pulse  is  of  value  for  diagnosis,  and  how  it  can  be 
turned  to  account. 

1.  The  pulse  very  often  directly  serves  to  determine  the  diagnosis ; 
not  that  it  alone  is  sufficient,  but  in  connection  with  other  phenomena 
it  is.  We  are  to  bear  in  mind  here  what  has  previously  been  said 
regarding  the  behavior  of  the  pulse  in  the  various  febrile  diseases. 
But  in  diseases  of  the  heart  it  especially  has  such  an  important  place 
that  a  diagnosis  is  never  to  be  made  without  taking  into  consideration 
the  condition  of  the  pulse. 

In  what  follows  is  brought  together  what  can  be  said  regarding  the 
behavior  of  the  pulse  in  the  most  important  of  the  diseases  of  the 
heart. 

In  jnitral  insufficiency  the  pulse  does  not  markedly  or  notably  vary 
from  the  normal.  But  in  addition  the  signs  of  hypertrophy  of  the 
right  and  left  ventricles  are  present :   systolic  murmur  at  the  apex. 

Mitral  stenosis :  Pulse  absent,  unequal,  or  irregular,  its  frequency 
often  much  increased.  (In  addition,  signs  of  hypertrophy  of  the  right 
ventricle  and  a  presystolic  murmur  at  the  apex.) 

Aortic  insufficiency:  Pulse  quick,  frequency  either  normal  or 
increased ;  generally  equal  and  regular.  In  addition  there  are  the 
signs  of  hypertrophy  of  the  left  ventricle  and  a  diastolic  blowing 
murmur  at  the  aorta.  (For  the  conditions  at  certain  arteries,  etc.,  see 
p.  256.) 


252  SPECIAL  DIAGNOSIS. 

Stenosis  of  the  aorta :  Pulse  small,  slow,  normal  or  diminished  fre- 
quency, equal  and  regular.  In  addition,  signs  of  hypertrophy  of  the 
left  ventricle ;  only  the  apex-beat  is  often  very  strong  and  a  systolic 
murmur  heard  over  the  aorta. 

Myocarditis:  Pulse  more  or  less  small  and  soft,  almost  always 
irregular  in  quality,  and  generally  so  in  time  (here  especially  we  have 
sometimes  pulsus  incidens,  higeminus).  Frequency  is  increased, 
normal,  or  diminished.  Nothing  abnormal  at  the  heart,  or  signs  of 
dilatation  of  one  or  both  ventricles  (or  of  hypertrophy) ;  no  murmurs. 

Pericarditis  exudativa:  Pulse  strong  if  the  heart  remains  so, 
generally  somewhat  quickened.  In  addition,  at  the  heart  all  signs 
of  its  activity  diminished  or  removed  by  being  covered  over,  marked 
dulness ;  in  paralysis  of  the  heart  no  pulse,  or  very  much  quickened ; 
sometimes  pulsus  paradoxus. 

We  are  particularly  to  notice  the  opposite  condition  of  the  pulse  in 
aortic  insufficiency  and  stenosis,  and  also  that  in  myocarditis  the  pulse 
may  be  the  only  sign. 

In  combined  valvular  disease  the  pulse  is  of  importance  in  two 
ways  :  it  betrays  the  existence  of  a  second  valvular  disease  besides  the 
one  already  made  out,  as  is  especially  the  case  in  mitral  insufficiency 
and  stenosis.  The  latter  near  the  former  may  be  overlooked  because 
very  slight,  or  may  even  be  entirely  wanting,  and  because  it  produces 
hypertrophy  of  the  right  ventricle,  which  is  also  produced  by  the 
former,  for  there  may  be  a  very  small,  unequal,  irregular  pulse,  which 
alone  indicates  the  stenosis.  Also,  an  aortic  stenosis,  besides  insuffi- 
ciency of  the  aorta,  is  sometimes  certainly  discovered  only  by  the 
pulse,  since  there  may  be  a  weak  systolic  murmur  at  the  aorta  without 
stenosis.  Thus  the  question  as  to  which  cardiac  orifice  is  concerned 
in  the  murmur,  or  whether  we  have  one  murmur  widely  conducted,  or 
two  murmurs  independent  of  each  other,  may  be  determined  by  the 
pulse. 

Moreover,  in  a  patient  with  combined  valvular  disease  the  pulse 
may  very  greatly  assist  in  determining  which  disease  is  the  more 
marked  or  important.  This  is  especially  true  in  insufficiency  and 
stenosis  of  the  aorta  (the  distinctness  of  the  murmurs  is,  of  course,  not 
at  all  indicative,  see  above),  also  of  the  mitral,  or  for  combined  disease 
of  the  aortic  and  mitral  valves. 

Thus  we  would  diagnosticate  a  preponderating  insufficiency  and  a 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.        253 

very  slight  stenosis  of  the  aorta  when  we  have  the  signs  of  hyper- 
trophy of  the  left  ventricle,  a  loud  sawing  systolic  and  a  very  slight 
diastolic  aortic  murmur  and  a  pronounced  j?it?SMS  celer.  Thus,  with 
the  signs  of  aortic  insufficiency  and  mitral  stenosis,  a  very  small  pulse 
points  to  the  preponderance  of  the  latter. 

It  is  impossible  to  make  a  diagnosis  of  the  particular  heart-lesion, 
either  from  the  general  symptoms  or  from  the  pulse,  so  long  as  there 
is  continued  evidence  of  incompensation. 

Moreover,  in  the  cases  where  the  heart  and  its  action  are  concealed, 
especially  in  pericarditis  exudativa,  also  in  emphysema,  sometimes  in 
marked  deformity  of  the  thorax,  displacement  of  the  heart,  tumors  of 
the  chest-wall,  the  pulse  is  the  only  sure  sign  of  what  work  the  left 
ventricle  is  doing.  In  pericarditis  the  contrariety  that  exists  between 
a  diminishing  apex-beat,  the  slight,  almost  imperceptible,  heart-sound, 
and  a  strong  pulse,  is  sometimes  a  very  important  diagnostic  point. 

2.  The  pulse  enables  us  to  judge  of  the  strength  of  the  heart  in  all 
other  possible,  especially  febrile,  diseases.  Even  the  first  examination! 
of  the  pulse  furnishes,  in  this  case,  important  information;  but  the 
signification  of  indications  furnished  by  repeated  examinations  of  the 
pulse  (palpation  and  representation  of  its  varying  frequence  upon  the 
temperature-chart)  becomes  very  much  more  valuable.  These  indica- 
tions furnish  still  more  important  diagnostic  points,  some  of  which 
have  already  been  spoken  of.  They  have  reference  to  the  beginning 
of  complications  in  acute  infectious  diseases,  especially  those  affecting 
the  heart,  the  lungs  (which  are  very  frequent),  the  kidneys,  as  in  scarlet 
fever,  when  the  pulse  has  greater  tension  and  diminished  frequence, 
and  to  the  brain  (decline  in  frequency  in  meningitis) ;  also,  the  effect 
of  treatment,  as  of  cold  baths,  may  be  determined  partly  by  the  behavior 
of  the  pulse ;  in  general,  it  often  determines  the  treatment ;  further, 
we  are  to  mention  all  diseases  which  in  any  way  affect  the  heart,  as 
pleuritis,  pericarditis,  peritonitis,  in  which  the  pulse,  especially  as  a 
measure  of  treatment,  has  any  part. 

II.    OTHER    PHENOMENA    IN    ARTERIES, 

•  The  Aorta. — Sometimes  a  pulsation  is  to  be  seen  and  felt  in  the 
neck ;  exceptionally,  also,  in  health  (higher  location  of  the  arch) ; 
likewise,  in  hypertrophy  of  the  left  ventricle  (most  marked  in  aortic 


254  SPECIAL  DIAGNOSIS. 

insufficiency,  since  this  causes  a  broadening  of  the  commencement  of 
the  aorta) ;  and,  finally,  in  aneurism  of  the  arch  of  the  aorta. 

The  occurrence  of  pulsation  that  can  be  seen  and  felt  in  the  right 
second  intercostal  space  is  always  pathological.  It  occurs  in  hyper- 
trophy of  the  left  ventricle,  and  also  especially  in  insufficiency  of  the 
aorta  ;  further,  in  aneurism  of  the  aorta,  see  below.  In  rare  cases, 
when  there  is  marked  hypertrophy,  the  second  aortic  sound  may  be 
felt  (of  course,  this  can  never  occur  in  aortic  insufficiency). 

In  rare  cases  of  aortic  insufficiency  the  commencement  of  the  aorta 
is  accessible  for  percussion.  It  is  to  be  remembered  that  here  it  is 
very  much  broadened,  and  to  the  right  of  the  sternum,  from  the  lower 
border  of  .the  second  rib  to  the  third  rib,  there  is. a  small  area  of  dulness. 
Sometimes  over  the  aorta  (in  the  right  second  intercostal  space),  in 
marked  atheroma,  there  ought  to  be  heard  a  systolic  murmur,  even 
when  there  is  no  endocarditis  aortica. 

Aneurism  of  the  aorta  requires  a  special  description.  It  most 
frequently  occurs  in  the  ascending  portion  or  the  arch  of  the  aorta, 
and  gives  rise  to  the  following  phenomena :  Only  when  the  aneurism 
is  large  is  a  swelling  to  be  seen,  and  this,  if  present,  is  seen  either 
above  the  sternum  or  close  to  the  right  of  it.  It  generally  pulsates — 
that  is,  becomes  larger  in  all  directions — with  the  systole  of  the  heart. 
From  stagnation  (see  p.  261)  the  enlarged  veins  of  the  skin  are  very 
early  visible  ;  later  they  may  become  red  from  inflammation,  or  even  be 
necrotic.  In  large  aneurism,  under  some  circumstances,  when  we  pal- 
pate, we  feel  the  pulsation,  and  besides,  not  infrequently,  a  peculiar 
whizzing  or  thrill.  With  large  tumors,  also,  it  further  shows  that  the 
bones  and  cartilages  over  them  have  been  absorbed.  Repeated  meas- 
urement of  the  thorax  shows  a  gradual  increase  of  the  sterno-vertebral 
diameter.  Percussion  generally  very  early  exhibits  dulness,  usually  on 
the  right,  close  to  the  sternum  and  over  the  manubrium  ;  more  rarely 
to  the  left  of  the  sternum,  and  this  either  in  connection  with  the  area 
of  heart-dulness  or  distinct  from  it.  Auscultation  not  infrequently  re- 
veals the  systolic  whizzing,  which  has  already  been  referred  to  as  being 
felt,  or  also  only  two  dull,  impure  sounds,  or  they  may  not  be  heard  at 
all.  The  radial  pulse,  also  the  carotid,  is  not  infrequently  early  upon 
one  side  smaller  and  a  little  later  than  on  the  other  in  consequence  of 
the  compression  of  the  particular  branches  of  the  aorta  or  distortion  of 
their  openings  at  the  point  of  origin.    Aneurism  of  the  ascending  aorta 


EXAMIXATION  OF  THE  CIRCULATOR V  APPARATUS.        255 

affects  the  vessels  of  the  right  side,  and  of  the  arch  of  the  aorta  some- 
times affects  those  of  the  left  side.  Not  infrequently,  also,  there  exists 
insufficiency  of  the  aorta  with  hypertrophy  of  the  heart.  As  by  all 
tumors  in  its  neighborhood,  the  heart  may  be  crowded  toward  the  left 
side ;  also,  we  see,  in  examining  the  larynx,  evidences  of  pressure  by 
these  tumors  upon  the  trachea,  the  oesophagus,  the  left  (seldom  the 
right)  recurrent  nerve,  and  the  large  veins  of  the  body  (p.  261). 

Aneurism  of  the  inywminate  produces  about  the  same  symptoms  as 
aneurism  of  the  ascending  aorta,  only  generally  somewhat  higher  up. 

Aneurism  of  the  descending  aorta  (rare)  may  cause  corresponding 
phenomena  upon  the  left  side,  posteriorly,  near  the  spine.  The  pulse 
in  the  abdominal  aorta  and  its  branches  is  usually  later. 

Aneurism  of  the  abdominal  aorta  (likewise  rare)  is  generally  at  the 
level  of  the  tripus  coeliacus.  It  may  be  felt  as  a  pulsating  tumor  in 
the  upper  part  of  the  abdomen,  and  sometimes  exhibits  the  whizzing 
mentioned  above. 

Considerable  stenosis  or  eve7i  closure  of  the  aorta  at  the  junction  of 
the  ductus  arteriosus  is  a  very  rare  congenital  condition  which  is  recog- 
nized by  the  fact  that  certain  arteries  furnish  collateral  circulation 
between  the  ascending  aorta  and  the  region  of  the  descending  thoracic 
aorta,  or  the  abdominal  aorta.  These  collateral  vessels  become  very 
much  enlarged,  and  pulsate  so  as  to  be  seen  and  felt.  Diagnostically, 
the  most  important  are  the  internal  mammary,  the  anterior  superior 
and  inferior  epigastric  anteriorly,  the  transversus  scapulae  and  dorsalis 
posteriorly. 

The  Pulmonary  Artery. — In  very  rare  cases  aneurism  of  the 
pulmonary  artery  may  give  rise  to  almost  the  same  symptoms  as 
aneurism  of  the  aorta,  except  in  being  at  the  left  of  the  sternum.  A 
systolic  murmur  over  the  pulmonary  artery  may,  besides,  be  caused  by 
stenosis  of  the  pulmonary  opening  or  by  narrowing  of  the  artery  itself. 
This  may  be  congenital  or  be  developed  later,  in  the  latter  case  by 
shrinking  of  the  upper  portion  of  the  left  lung.  In  such  cases  the 
second  pulmonary  sound  is  generally  accentuated  (hypertrophy  of  the 
right  ventricle),  and,  under  some  circumstances,  may  even  be  felt  (see 
above). 

The  Other  Arteries. — Excepting  during  excitement  of  the  heart 
(by  mental  excitement  or  physical  exertion),  we  observe  in  health  a 
visible  pulsation  of  the  carotid  in  the  neck  just  under  the  angle  of  the 


256  SPECIAL  DIAGNOSIS. 

jaw  ;  also  of  the  temporal  artery,  A  marked  pulsation  of  the  carotid, 
especially  when  there  is  perfect  mental  and  physical  quietude,  or, 
again,  a  general  visible  pulsation  of  smaller  vessels,  as  of  the  temporal, 
the  brachial,  in  the  sulcus  of  the  brachial  muscle  or  at  the  bend  of  the 
elbow,  of  the  radial,  peroneal,  dorsalis  pedis,  points  to  hypertrophj  of 
the  left  ventricle.  These  abnormal  pulsations  are  most  marked  in 
insufficiency  of  the  aortic  valves  and  in  arterial  sclerosis  ;  in  the  first 
case  on  account  of  the  fulness  of  the  pulse,  in  the  latter  case  on  account 
of  the  thickened  and  stiffened  vessels  being  prominent.  In  both 
classes  of  cases  the  smaller  arteries  are  very  tortuous. 

Here,  also,  a  capillary  pulse  is  to  be  mentioned  :  alternating  between 
marked  fulness  and  emptiness  of  the  capillaries  occasioned  by  the 
pulse  in  the  arteries,  the  pulse  may  become  visible  under  the  finger- 
nails, more  rarely  over  the  tendons,  in  case  these  variations  are  con- 
nected with  a  large  and  quick  pulse  in  the  arteries,  which,  in  turn, 
have  large  and  quick  alternations  of  size.  Then,  in  examining  the 
finger-nail,  we  see  the  red  part  rhythmically  become  alternately  white 
and  red :  capillary  pulse  of  the  bed  of  the  nail.^  This  is  a  sign  of 
aortic  insufficiency  with  marked  hypertrophy  of  the  left  ventricle 
(which  would  also  be  present  in  some  cases  of  marasmus). 

Palpation.  Medium-sized  and  small  arteries  sometimes  feel 
thickened  and  moderately  stiff,  or  scattered  in  their  walls  we  feel 
separate  rigid  patches,  very  like  the  plates  of  cartilage  of  the  bronchial 
tubes,  or  the  rings  of  a  small  trachea  ("  goose's  throat  ").  The  latter 
become  especially  plain  if  we  slip  the  tip  of  the  finger  up  and  down 
along  the  course  of  the  artery.  This  is  the  condition  in  arterial 
sclerosis.  Hence,  the  vessels  are  often  tortuous  (see  above),  and  show 
variations  of  the  pulse  (see).  It  is  very  easy  to  recognize  arterial 
sclerosis  in  the  temporal,  radial,  and  brachial  arteries.  From  the 
condition  of  these  we  can  correctly  estimate  the  condition  of  other 
arteries  of  the  same  size. 

Palpation  of  the  radial  artery  has  already  been  described.  Of  the 
other  arteries  of  the  extremities  the  pulse  of  which  we  can  feel  in 
health,  we  may  mention  the  brachial,  in  many  persons  the  ulnar,  the 
crural,  the  popliteal,  and  in  most  people  the  peroneal.     Increased 

r^  This  is  often  an  unfavorable  situation  for  making  the  observation.  Quincke,  who 
first  described  the  capillary  pulse,  now  recoui mends  rubbing  gently  a  spot  upon  the 
forehead.     Berliner  klin.  Wochenschr.,  March  24,  1890.] 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.        257 

pulsation  in  arteries  that  can  be  felt,  its  occurrence  in  small  arteries 
that  can  be  felt,  which  in  health  are  never  made  out,  takes  place  in 
aortic  insufficiency.  A  pulsation  that  can  be  felt  in  the  dorsalis  pedis 
artery  is  here  very  frequent,  but  the  same  thing  may  take  place  in 
still  smaller  arteries — in  the  digital,  in  the  coronarise  labii  inferior., 
superior.,  and  the  like.  Very  exceptionally  in  aortic  insufficiency  we 
may  even  observe  an  "arterial  liver-pulse" — that  is,  a  continuous 
to-and-fro  swelling  of  the  liver  from  the  marked  pulse  in  the  arteries 
of  the  liver  (quite  like  the  venous  liver-pulse,  see  p.  266).  Still  more 
rare  is  an  arterial  pulse  at  the  spleen  (see  under  Examination  of  the 
Spleen). 

When  in  symmetrical  vessels,  like  the  two  radials,  we  find  a  pulse 
that  is  unequal  as  to  strength  or  time,  we  may  generally  conclude 
that  there  is  a  mechanical  hindrance  to  the  passage  of  the  blood- 
current.  We  then  have  to  seek  toward  the  centre  from  the  weaker  or 
later  pulsating  artery  for  a  compressing  tumor,  thrombosis  (autoch- 
thonous or  embolic),  or  for  an  aneurism.  Moreover,  there  are 
observed  variations  of  the  pulse  in  symmetrical  vessels,  caused  by 
vasomotor  influences  from  the  nerve-centres.  Finally,  we  must  not 
overlook  the  possibility  of  anatomical  variations. 

Auscultation.  Mode  of  procedure :  Here,  it  is  to  be  understood 
throughout,  the  stethoscope  is  to  be  employed,  and  that  ordinarily  it 
is  to  rest  upon  the  surface  without  pressure.  We  auscultate  the 
carotid  with  the  neck  somewhat  extended,  but  not  stretched,  in  the 
intersterno-cleido-mastoid  fossa  or  at  the  angle  of  the  jaw;  the  sub- 
clavian, in  the  angle  between  the  clavicle  and  the  clavicular  head  of 
the  sterno-cleido-mastoid  muscle;  the  brachial,  on  the  inner  border  of 
the  biceps  in  the  bend  of  the  elbow,  with  the  arm  slightly  extended  ; 
the  crural,  close  below  Poupart's  ligament. 

Normal  conditioyi.  In  health  we  usually  hear  over  the  carotid,  as 
well  as  the  subclavian,  two  sounds — one  corresponding  to  the  pulse, 
with  the  systole  of  the  heart  (the  conducted  aortic  first  sound  and  local 
diastolic  sound  in  the  vessel).  In  individual  cases  the  first  sound  is 
impure,  or  is  entirely  wanting.  In  health  the  diastolic  heart-sound 
is  never  wanting.  We  sometimes  hear  over  the  abdominal  aorta  and 
the  crural  artery  a  sound  which  corresponds  with  the  pulse,  or  at  any 
rate  arises  locally  from  the  tension  of  the  vessels.  We  usually  hear 
nothing  over  any  of  the  small  vessels.     If  we  press  with  the  stetho- 

17 


258  SPECIAL  DIAGNOSIS. 

scope  over  the  given  vessel,  then  we  hear  the  so-called  acoustic 
pressure-sound,  not  alone  over  the  aorta  and  subclavian,  but  also 
regularly  over  the  abdominal  aorta  and  crural  artery,  and  usually, 
also,  over  the  brachial.  Thus,  over  these  vessels  by  moderate  pressure 
we  hear  a  pressure-murmur  corresponding  to  the  arterial  pulse ;  by 
stronger  pressure,  which  almost,  but  not  quite,  closes  the  artery,  this 
murmur  is  changed  into  a  tone — pressure-tone.  That  these  acoustic 
phenomena,  resulting  from  pressure,  are  everywhere  present,  are  the 
chief  reasons  why  the  pathological  conditions  over  the  large  vessels, 
which  are  to  be  mentioned  later,  have  only  conditional  diagnostic 
value. 

We  must  also  mention  a  phenomenon  frequently  present  in  healths/ 
children,  called  "cerebral  blowing";  it  is  heard  between  the  third 
month  and  the  sixth  year,  with  the  systole  of  the  heart,  or,  more 
exactly,  as  a  blowing  corresponding  with  the  carotid  pulse,  which  is 
heard  sometimes  light,  sometimes  tolerably  loud,  over  the  fontanelle 
while  still  open,  but  also  sometimes  after  it  has  closed,  and  elsewhere 
over  the  head.  Jurasz  has,  in  most  cases,  found  at  the  same  time  a 
Wowing  over  the  carotid,  and  thinks  that  the  cerebral  blowing  is 
merely  this  murmur  conducted  upward.  He  explains  the  latter  by 
the  compression  which  the  carotid  sustains  in  the  carotid  canal  during 
the  development  of  the  skull. 

Pathological  conditions.  In  aortic  stenosis  there  will  be  heard 
over  the  carotid,  in  place  of  the  first  sound,  a  rough  systolic  heart- 
murmur  (the  stethoscope  must  rest  very  lightly). 

In  aortic  insufficiency  the  second  sound  of  the  carotid  and  sub- 
clavian is  wanting,  or  it  is  replaced  by  blowing  with  the  diastole  of 
the  heart  (rare).  This,  as  well  as  the  systolic  murmur  previously 
mentioned,  is  conducted  from  the  mouth  of  the  aorta.  The  former, 
arising  in  a  current  of  blood  flowing  forward,  would  naturally,  as  a 
rule,  be  more  loudly  conducted  than  the  latter,  which  comes  from  a 
backward-flowing  blood-current. 

Sounds  in  such  arteries  as  in  health  very  seldom  or  never  furnish  a 
sound,  accompany  aortic  insufficiency,  being  produced  by  the  quick 
and  strong  tension  of  the  vessels  during  their  diastole.  We  then  hear 
a  sound  corresponding  with  the  pulse  over  the  crural,  brachial,  radial, 
even  the  ulnar,  peroneal,  dorsalis  pedis  arteries ;  sometimes,  even, 
over  still  smaller  vessels.     A  sound  is  also  observed  over  the  crural 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.       259 

in  high  fever.,  as  well  as  in  ancemia  and  chlorosis  (and  as  well  in  some 
healthy  persons). 

A  double  sound  over  the  crural  artery  (Traube)  is  heard  in 
individual  cases  of  aortic  insufficiency.  But  this  phenomenon  has 
also,  although  very  exceptionally,  been  observed  with  mitral  stenosis 
(Weil),  likewise  in  lead-poisoning  (Matterstock),  lastly,  in  pregnancy 
( Gerhard t).  Much  more  important  is  the  double  murmur  which  is 
heard  Avhen  considerable  pressure  is  made  with  the  stethoscope — 
Duroziez's  double  murmur.  In  the  experience  of  observers  thus  far, 
this  occurs  only  Avith  aortic  insufficiency,  and  this  when  there  is  good 
compensation,  and  this  has  ail  the  greater  significance  from  the  fact 
that  it  is  decidedly  more  frequent  than  was  previously  supposed. 

Double  sound,  as  well  as  double  murmur,  can  only  occur  when 
there  is  a  large  and  quick  pulse.  In  the  first  phenomenon,  the  double 
sound  is  caused  by  the  sudden  collapse  of  the  artery ;  with  double 
murmur,  the  second  murmur  is  probably  to  be  explained  by  the  short 
reflux  blood-current  which  may  be  assumed  to  flow  into  the  large 
vessels  when  there  is  aortic  insufficiency  (?).  A  double  sound  can 
also  be  heard  over  the  crural  artery  if  one  of  the  two  sounds,  or  even 
if  both  sounds  arise  from  the  crural  vein.  (See,  regarding  this,  in 
the  next  chapter.) 

A  systolic  subclavian  murmur  is  sometimes  heard  on  both  sides,  or 
sor-etimes  only  on  one  side  (especially  the  left),  as  a  very  disturbing 
addition  to  the  breath- sounds  at  the  apex  of  the  lungs.  It  is  stronger, 
or,  perhaps,  only  to  be  heard  toward  the  end  of  inspiration.  When 
it  occurs  upon  both  sides  it,  as  a  rule,  does  not  indicate  a  pathological 
condition ;  when  unilateral  it  also  has  no  significance,  and  yet  it 
always  gives  the  suspicion  of  phthisis,  with  which  we  often  meet  it. 
It  is  explained  by  a  temporary  pulling  or  bending,  and,  hence,  nar- 
rowing of  the  subclavian  artery  during  deep  breathing.  In  phthisis 
this  is  caused  by  adhesion  of  the  pleural  surfaces  at  the  anterior  sur- 
face of  the  apex  of  the  lungs.  We  do  not  know  exactly  why  this 
murmur  occurs  also  with  persons  apparently  perfectly  healthy,  but  it 
may  possibly  be  from  the  same  cause. 

Loud  blowing  murmurs  over  the  thyroid  glands  sometimes  occur 
in  all  forms  of  struma.  These  murmurs  may  be  felt.  They  are  not 
infrequent  with  struma  of  Basedow's  disease,  but  here  they  are  caused 
by  the  excited  action  of  the  heart. 


260  SPECIAL  DIAGNOSIS. 

The  murmurs  which  in  some  cases  are  heard  over  aneurism  have 
been  already  mentioned. 

Examination  of  the  Veins. 

We  examine  chiefly,  in  many  cases  exclusively,  the  jugular  veins 
(external  and  internal  in  the  neck),  but  also  the  cutaneous  veins  of 
the  body  and  extremities.  Only  in  special  cases  (thrombosis)  do  the 
deep  veins  of  the  extremities  become  accessible  for  examination.  The 
ophthalmoscopic  examination  of  the  ophthalmic  veins  does  not  come 
within  the  scope  of  this  book.  It  is  important  that  we  are  able  to 
judge  of  the  abnormal  fulness  (engorgement)  of  certain  deep  veins  by 
its  effect  upon  particular  internal  organs,  as  enlargement  of  the  liver 
and  spleen,  also  ascites,  and,  lastly,  the  suppression  of  urine. 

The  examination  of  the  veins  is  made  by  inspection,  or  sometimes 
by  palpation,  and  auscultation. 

INSPECTION    AND    PALPATION    OF    VEINS. 

By  these  means  we  ascertain  the  degree  of  fulness,  the  condition  of 
the  circulation,  and,  under  some  circumstances,  the  existence  of  venous 
thrombosis.  An  unusually  empty  condition  of  the  veins  does  not 
come  under  consideration.  This  would  also  be  very  difficult  to  deter- 
mine, for  the  reason  that  even  in  health,  especially  in  fat  people,  the 
superficial  veins  may  be  indistinct  or  entirely  invisible. 

It  remains  to  describe  :  1.  Increased  fulness  of  veins  ;  2.  Circu- 
lation in  the  veins  of  the  neck ;  3.  Circulation  in  the  other  veins  ; 
4.  Venous  thrombosis. 

1.  Increased  Fulness  of  Veins. 

This  is  the  result  of  stoppage  of  the  blood  in  its  course  toward  the 
centre.  It  is  general  or  local,  according  to  the  cause  of  the  engorge- 
ment— whether  this  be  central  or  at  some  place  in  the  course  of  the 
nerves  that  control  the  circulation. 

General  increased  fulness  is  the  result  of  general  venous  engorge- 
ment. We  first  recognize  it  by  the  swelling  of  the  internal  and 
external  jugular  veins  upon  both  sides.  The  first  of  these  is  usually 
visible  in  health  (but  not  always,  especially  in  fat  people),  coursing 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.        261 

obliquely  over  the  sterno-cleido-mastoid  muscle.  When  the  head  is 
turned  toward  the  opposite  side  it  usually  swells  still  more.  With 
the  increased  fulness  it  becomes  distinct,  perhaps  can  be  felt.  With 
normal  fulness  the  internal  jugular  cannot  be  made  out,  situated,  as 
it  is,  under  the  sterno-cleido-mastoid  muscle,  where  it  is  divided  into 
the  clavicular  and  sternal  portion  just  in  the  angle  between  these  at 
the  bottom  of  the  intersterno-cleido-mastoid  fossa.  Where  it  passes 
into  the  bulbus  jugularis  it  has  a  valve  (ordinarily  exactly  at  the 
upper  border  of  the  sterno-clavicular  articulation,  but  sometimes, 
especially  in  consequence  of  the  engorgement,  located  somewhat 
higher  up).  Abnormal  fulness  of  the  jugular  vein  fills  up  the  inter- 
sterno-cleido  mastoid  fossa,  or  it  may  cause  a  projection  there. 
Dorsal  posture  increases  the  fulness.  Fulness  of  the  cutaneous  veins 
of  the  trunk  and  extremities,  not  occurring  without  general  engorge- 
ment, is  usually  not  so  pronounced  as  that  of  the  veins  of  the  neck, 
especially  on  account  of  the  marked  oedema  which  accompanies  the 
congestion.  Important  associated  symptoms  of  general  engorgement 
are  cyanosis,  oedema,  effusion  into  the  cavities  of  the  body,  enlarge- 
ment of  liver  and  spleen,  disturbance  of  the  bowels,  and  so-called 
concentrated  urine  (which  see). 

This  condition  arises  when  the  right  heart  is  not  able  to  propel  the 
required  (quantity  of  blood  into  the  lungs.  It  occurs  in  various  dis- 
eases of  the  heart,  in  emphysema  of  the  lungs,  and  in  all  the  conditions 
that  lead  to  marked  interference  with  the  action  of  the  heart,  especially 
pericarditis.  The  most  marked  engorgement  occurs  in  general  when 
the  right  side  of  the  heart  is  paralyzed  after  it  has  been  obliged  for  a 
long  time  previously  to  meet  unusual  demands,  and  hence  has  become 
hypertrophied  ;  hence  with  mitral,  and,  more  rarely,  pulmonary  defects 
and  emphysema,  and  likewise,  in  the  very  rare  tricuspid  stenosis  and 
insufficiency  (see  under  3). 

General  abnormal  fulness  of  the  veins  may  also  be  the  result, 
exceptionally,  of  diminished  flow  of  blood  from  the  two  cavge  into  the 
right  auricle  in  consequence  of  pressure  by  a  mediastinal  tumor. 

Local  increased  fulness  of  the  veins  maybe  caused  by  a  considerable 
narrowing  or  closure  anywhere  of  a  venous  trunk  by  a  thrombus  or  by 
compression.  The  larger  the  vessel  thus  affected,  the  more  extensive 
the  area  of  abnormal  fulness.  Thus  sometimes  abnormal  fulness  of 
the  jugular  and  its  branches,  aJso  of  the  ophthalmic  vein  (recognized 


262  SPECIAL  DIAGNOSIS. 

by  the  ophthalmoscope),  will  be  caused  by  a  mediastinal  tumor  which 
presses  upon  the  cava.  Also  the  superficial  veins  of  the  skull  between 
the  ear  and  the  fontanelle  will  become  distended  and  tortuous  if  the 
longitudinal  sinus  of  the  dura  is  stopped.  Fulness  of  the  veins  of  an 
arm  points  to  compression  of  the  axillary  vein  (generally  tumors  or 
scars  from  operations  in  the  axilla).  The  swelling  of  single  small 
cutaneous  veins  over  the  sternum  and  in  its  neighborhood  is  a  very 
important  early  sign  of  mediastinal  tumor.  The  cutaneous  veins  of 
the  leg  are  enlarged  when  there  is  thrombosis  or  compression  of  the 
femoral  vein  of  that  side.  The  veins  of  both  legs  may  swell  as  the 
result  of  double  thrombosis  or  compression  of  the  vena  cava  inferior 
or  both  iliac  veins  (ascites,  tumors).  In  all  these  cases  there  may  be 
local  oedema  (which  see).  This  may  even  give  a  better  and  earlier 
sign  of  local  engorgement,  but,  on  the  other  hand,  it  may  conceal  the 
fulness  of  the  veins. 

In  the  majority  of  such  cases  the  cutaneous  veins  supply  the  neces- 
sary collateral  circulation.  But  this  is  especially  the  case  in  engorge- 
ment of  the  portal  vein  (see  also  Enlargement  of  the  Spleen  and 
Ascites),  Avhether  due  to  cirrhosis  of  the  liver  or  compression  or 
thrombosis  of  the  portal  trunk.  Here  we  may  see  the  abdominal 
veins  enlarged,  part  of  which  go  upward  to  the  thorax  and  part  down 
to  the  inguinal  region.  In  individual  cases  there  is  a  crown  of  such 
veins  around  the  navel — "  caput  Medusae  " — since  the  umbilical  vein, 
remaining  open,  receives  a  part  of  the  overflow  of  blood  which  the 
portal  is  not  able  to  carry. 

Very  extensive  enlargement  and  tortuosity  of  a  large  part  of  the 
cutaneous  veins  of  the  trunk,  or  of  the  chest  (generally  symmetrical), 
or  enlargement  of  single  cutaneous  veins  of  an  extremity  also  occurs 
without  any  possible  assignable  cause  (perhaps  closure  of  a  deep 
branch),  so  that  recently  Ave  are  inclined  to  the  assumption  that  in 
such  cases  there  is  a  congenital  condition  or  disease  of  the  Avail  of  the 
vein  itself. 

2.  Phenomena  of  Circulation  in  the  Jugular  Veins. 

Respiratory  motions.  The  suction-action  of  the  chest  with  inspi- 
ration causes  a  rapid  emptying  of  the  blood  from  the  veins  of  the  body 
into  the  heart  during  inspiration,  as  well  as  during  expiration.      On 


EXAMIXATJOy  OF  THE  CIRCULATORV  APPARATUS.        263 

the  other  hand,  a  forced  expiration,  likewise  strong  effort,  and  very 
especially  the  increased  internal  pressure  within  the  chest  which 
takes  place  in  coughing  before  each  cough-impulse,  checks  the  dis- 
charge. The  alteration  in  the  fulness  of  the  veins  in  the  neighbor- 
hood of  the  heart  which  is  thus  caused  is  usually  only  to  be  ob- 
served in  the  jugular  veins.  But  in  normal  fulness  of  these  veins  the 
simple  respiratory  oscillation  of  their  volume  is  not  noticeable.  Such 
veins  only  distinctly  swell  with  marked  pressing  and  coughing  (whoop- 
ing-cough), and  then  the  veins  of  the  face  become  very  full.  Yet 
when  the  veins  of  the  neck  are  constantly  abnormally  full  or  engorged, 
then  in  ordinary  breathing  they  show  a  corresponding  to-and-fro 
swelling,  and  with  forced  expiration,  pressing  or  coughing,  they  stand 
out  very  distinctly.  The  bulbus  jagularis  may  then  appear  as  a  round 
bunch  between  the  heads  of  the  two  sterno-cleido-mastoidei  muscles ; 
but  even  the  whole  internal  jugular  may  swell  and  contract  if  the 
valve  over  the  bulb  does  not  close.  This  phenomenon  occurs  in  the 
most  marked  degree  with  the  labored  expiration  of  emphysema. 
Here,  also,  in  very  rare  cases,  this  variation  in  the  fulness  extends  to 
the  cutaneous  veins  of  the  face,  the  chest,  and  arms. 

The  opposite  condition  of  the  veins  of  the  neck,  becoming  tumid 
with  inspiration  and  emptying  with  expiration,  may  be  caused  by 
fibroid  mediastinitis  (mediastino-pericarditis).  The  cause  of  the  phe- 
nomenon, like  that  o^ pulsus  pco'adoxus  (which  see),  is  the  traction  and 
bending  of  the  large  vessels  during  inspiration  (Kussmaul). 

Venous  pulse.  Circulatory  movements  in  the  veins  or  the  neck, 
which  directly  or  indirectly  depend  upon  the  action  of  the  heart,  and 
hence  are  rhythmic,  are  designated  as  venous  pulse.  This  motion 
may  be  communicated,  or  be  really  in  the  vessels  (autochthonous,  real 
pulse).  The  former  is  only  the  pulsation  in  the  carotid  communicated 
to  the  internal  jugular,  which  shows  most  frequently  and  plainly  when 
the  carotid  pulsates  very  strongly,  or  when  the  internal  jugular  is 
very  full,  or  if  both  conditions  exist.  (For  distinction  between  this 
and  genuine  systolic  venous  pulse,  see  p.  267.) 

We  divide  the  real  venous  pulse,  pulsation  in  the  veins  of  the  neck, 
into  that  which  occurs  in  health,  the  so-called  "normal,"  or  negative; 
and  the  positive,  which  is  always  pathological.  The  normal  venous 
pulse  is  presystolic,  and  usually  is  only  observed  in  the  external 
jugular.       It  would  be  best   designated  as   a   collapse   of  the  vein 


264 


SPECIAL  DIAGNOSIS. 


accompanying  the  systole  of  the  heart ;  for  the  external  jugular,  ex- 
actly corresponding  with  the  apex-beat  and  the  carotid  pulse,  quickly 
empties  itself  and  immediately  again  slowly  fills,  sometimes  visibly  in 
two  intervals,  so  that  it  attains  its  complete  distention  before  the  next 
systole  of  the  heart,  and  hence  is  presystolic. 

This  phenomenon  depends  upon  the  part  the  auricle  plays  in  the 
action  of  the  heart :   during  the  ventricular  systole  it  is  in  diastole, 


Fig.  74. 


Normal  venous  pulse  or  venous  collapse  with  systole  of  the  heart,   and  (broken  line) 
carotid  pulse.     ( After  Riegel.) 


and  thus  favors  the  flow  of  blood  from  the  veins.  Shortly  after  the 
beginning  of  the  ventricular  diastole  it  begins  to  contract,  and  thus 
the  flow  of  the  venous  blood  from  the  cava  into  the  auricle  is  impeded. 
It  seems  to  me  that  the  first  elevation  of  the  ascending  side  of  the 
tracing  of  the  curve  of  the  venous  pulse  has  not  yet  been  explained. 
In  health  this  pulse  is  seen  to  a  very  small,  scarcely  noticeable  degree  ; 
it  is  beautifully  seen  in  dogs  when  the  jugular  is  laid  bare.  In 
healthy  persons,  without  any  known  reason,  it  is  in  some  cases  strong 
enough  to  be  observed.  But  it  is  still  stronger  sometimes  when  the 
external  jugular  is  abnormally  full,  hence  in  engorgement.  Often 
this  pulse  occurs  only  indistinctly,  its  rhythm  is  difficult  to  recognize, 
and  also  aff"ected  by  the  pulsations  of  the  carotid.  Then  we  speak  of 
undulation  in  the  veins  of  the  neck. 

The  positive  venous  pulse  is  systolic,  hence  is  contemporaneous 
with  the  carotid  pulse.  It  is  a  pathognomonic  sign  of  insufficiency 
of  the  tricuspid  valve,  and  is  caused  by  the  contraction  of  the  right 
ventricle,  which  causes  a  regurgitant  positive  blood-wave  into  the  cava 
and  its  nearest  branches  through  the  imperfectly  closed  right  ostium 


EXAMINATION  OF  THE  CIRCULATOR V  APPARATUS. 


265 


venosum.  It  first  and  most  markedly  appears  in  the  internal  jugulars 
,  or  their  bulb,  and  generally  only  here.  The  very  direct  course  of  the 
innominate  and  right  jugular  from  the  cava  causes  the  right  jugular 
vein  to  show  the  phenomenon  more  frequently  and  stronger  than  the 
left. 

If  the  valve  of  the  vein  closes  above  the  bulb  of  the  jugular  then 
the  regurgitant  wave  ends  there.     This  pushes  the  bulb  up  and  dis- 

FiG.  75. 


Positive  jugular  pulse  compared  with  (Cj  carotid  pulse.     (After  Eiegel.) 


tends  it,  and  it  is  then  seen,  enlarged  and  pulsating,  in  the  inter- 
sterno-cleido-mastoid  fossa  (bulbar  pulse).  The  bound  of  the  pulse- 
wave  against  the  valve  sometimes  causes  a  valvular  sound  in  the 
jugular.  But  ordinarily  the  valve  is  insufficient  from  previous  en- 
gorgement (or  is  congenitally  so),  or  it  becomes  so  from  the  distending 
action  of  the  pulse,  and  then  the  pulse-wave  passes  into  the  internal 


266  SPECIAL  DIAGNOSIS. 

jugular,  and  exceptionally  also  into  its  branches  in  the  face.  This 
systolic  pulse  must  likewise  be  supposed  to  be  propagated  to  a  certain 
extent  also  in  all  other  veins  that  are  directly  given  off  from  the  cava ; 
but  they  cannot  be  examined  except  in  a  large  venous  territory :  the 
veins  of  the  liver.  Here  the  pulse  manifests  itself  by  a  constant 
systolic  swelling  and  diastolic  collapse  of  the  organ,  the  venous  liver 
puhe.  Palpation  of  a  liver  thus  constantly  enlarged  frequently 
shows  the  phenomenon  of  systolic  venous  pulse  to  a  high  degree. 

The  systolic  jugular  pulse  may  be  graphically  represented,  as  is 
shown  in  Fig.  75. 

The  mode  of  procedure  in  palpating  the  liver  is  as  follows :  One 
hand  is  placed  upon  the  right  hypochondrium  or  the  epigastrium,  the 
other  is  passed  around  the  chest  at  the  level  of  the  eleventh  and  twelfth 
ribs  posteriorly.  We  can  then  feel  that  the  organ  is  systolically 
enlarged,  and  thus  Ave  may  avoid  confounding  it  with  lifting  up  of  the 
liver  by  the  aorta  or  even  with  marked  epigastric  pulsation.  More- 
over, we  recognize  the  liver-pulse  in  this  way  easier — that  is  sooner — 
than  by  simply  palpating  in  front.  The  liver  is  usually  enlarged,  al- 
most always  by  the  previously  existing  engorgement  (see  Enlargement 
of  the  Liver) ;  at  least,  it  immediately  becomes  so  if  tricuspid  insuf- 
ficiency occurs,  as  we  very  distinctly  observed  in  a  case  of  mitral 
insufficiency  and  stenosis,  in  which  relative  tricuspid  insufficiency 
occurred,  then  subsided  and  again  reappeared. 

Arterial  liver-pulse  is  exactly  like  venous  liver-pulse  in  its  phenomena 
(in  aortic  insufficiency,  see  p.  257). 

For  the  production  of  a  recognizable  venous  liver-pulse,  as  well  as 
a  strong  jugular-pulse,  there  is,  of  course,  required  a  certain  moderate, 
and,  if  it  has  not  been  met  with  before,  also  it  must  not  be  too  fre- 
quent action  of  the  heart.  As  the  heart  grows  more  and  more  weak 
the  liver-pulse  fails  and  the  jugular-pulse  gradually  becomes  smaller 
and  more  slow,  until  finally  there  is  only  a  slight  to-and-fro  movement 
of  the  vein. 

In  order  to  make  a  differential  diagnosis  of  the  different  kinds  of 
pulse  in  the  veins  of  the  neck  it  is  necessary  to  bear  in  mind  the  fol- 
lowing :  1.  The  transmitted  pulse  will  be  best  distinguished  from  the 
positive  real  pulsation,  occurring  at  the  same  time  with  it,  by  placing 
the  finger,  or,  better  still,  a  pleximeter,  with  its  edge  in  the  middle  of 
the  neck  i  pon  the  vein  :  if  the  pulsation  is  communicated  it  disappears 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.       267 

in  the  central  empty  portion  and  becomes  more  distinct  in  the  periphery 
from  the  engorgement  of  the  distended  portion ;  on  the  other  hand,  a 
positive  genuine  pulse  remains  centrally  unchanged.  2.  The  negative 
true  pulse  is  distinguished  from  the  positive  and  from  the  communicated 
pulsation  generally  by  comparison  with  the  apex-beat  as  well  as  by 
comparison  with  the  carotid  pulse.  (We  seize  the  left  cax'otid,  and 
at  the  same  time  observe  the  right  jugular.)  It  is  also  to  be  observed 
that  with  the  negative  pulse  the  collapse  of  the  vein  is  usually  quick 
and  that  it  refills  slowly.  In  this  way,  with  a  little  practice,  one  can 
often  immediately  judge  correctly. 

In  order  more  exactly  to  observe  and  study  these  phenomena  it  is 
well  to  have  the  patient  for  a  time  breathe  very  superficially,  or,  if 
possible,  to  hold  the  breath,  so  as  to  eliminate  the  respiratory  to-and- 
fro  swelling  of  the  veins. 

We  must  still  mention  some  occurrences  that  are  extremely  rare  or 
are  of  very  little  diagnostic  value  : 

Diastolic  collapse  of  the  cervical  veins  (Friedreich),  which  looks 
very  like  systolic  venous  pulse,  sometimes  occurs  in  adhesive  pericar- 
ditis and  fibroid  mediastinitis,  and  is  connected  with  systolic  drawing- 
in  in  the  neighborhood  of  the  heart  which  occurs  with  this  condition. 
The  springing  forward  of  the  heart  in  the  diastole,  together  with  the 
forward  movement  of  the  anterior  wall  of  the  chest,  probably  pro- 
duces an  aspiration  of  the  contents  of  the  large  veins. 

Systolic  venous  pulse  may  exceptionally  occur  with  mitral  insuf- 
ficiency and  open  foramen  ovale :  through  the  latter  and  the  left 
ostium  venosum  the  contraction  of  the  left  ventricle  produces  a 
recurrent  pulse-wave  in  the  cavae  and  their  nearest  branches  (very 
rare,  being  thus  far  only  observed  in  one  case). 

Double  positive  venous  pulse  (Leyden)  is  observed  in  hemisystole. 

3.  Phenomena  of  Circulation  in  other  Veins. 

Systolic  true  pulse  may,  as  has  already  been  mentioned,  be 
propagated  to  the  veins  of  the  face,  but  this  is  rare.  It  has,  in 
individual  cases,  even  been  observed  in  the  cutaneous  veins  of  the 
arm,  in  the  small  branches  of  the  internal  mammary  (of  Avhich  I  have 
seen  one  case),  in  the  vena  cava  inferior  (Geigel),  etc. 

The  so-called  progressive  venous  pulse  (Quincke)  has  been  seen  in 


268  SPECIAL  DIAGNOSIS. 

the  veins  of  the  hand  and  the  back  of  the  foot  with  existing  capillary 
pulse  (aortic  insufficiency,  also  in  severe  anaemia ;  likewise  reported 
to  have  been  seen  in  health),  as  a  pulse-wave  flowing  centrally,  and 
later  appearing  as  the  radial  pulse  (a  very  great  rarity).  It  can 
be  regarded  as  nothing  else  than  the  arterial  pulse  propagated 
through  the  capillaries. 

4.    Venous  Thrombosis. 

The  transformation  of  the  soft  venous  tubes  into  firm  round  cords 
that  can  be  felt  exhibits  venous  thrombosis.  The  thrombosed  vein 
may  often  also  be  perceived  by  pressure.  In  internal  medicine,  of 
especial  interest  and  importance  is  thrombosis  of  the  large  veins  of  the 
lower  extremities  as  it  sometimes  occurs  in  the  course  of  severe  acute 
infectious  diseases,  as  the  result  of  chronic  invalidism,  and  in  marasmus 
of  the  aged.  Frequently,  but  never  while  resting  in  bed,  it  occurs  in 
the  oedema  of  engorgement  in  the  affected  limb. 

AUSCULTATION    OF    VEINS. 

1.  Sounds  and  murmurs  of  short  duration  are  sometimes  heard 
over  the  jugular  and  crural  veins  : 

In  tricuspid  insufficiency  there  is  a  systolic  recurrent  blood-wave, 
which,  by  its  impulse  against  the  closing  valve  above  the  bidbus 
jugularis  and  against  those  in  the  crural  vein  at  Poupart's  ligament, 
and  also  by  the  sudden  tension  of  the  vein  itself,  causes  a  sound  which 
will  be  heard  by  very  lightly  placing  the  stethoscope  at  these  points. 
But  a  sound  has  also  been  heard  where  the  crural  valve  was  defective. 
In  such  cases  it  must  be  alone  caused  by  the  sudden  tension  of  the 
venous  tube.  If  these  valves  are  insufficient  there  may  be  a  corre- 
sponding short  murmur  (very  rare). 

Jugular  sound  generally  accompanies  the  bulbar  pulse  of  tricuspid 
insufficiency.  A  venous'  sound  over  the  crural  is,  however,  rare, 
because  the  recurrent  wave  only  exceptionally  reaches  this  vessel. 
Quite  exceptionally  there  may  be  with  tricuspid  insufficiency  a  double 
sound  over  the  crural  vein,  indicating  first  auricular,  then  ventricular, 
contraction  (Friedreich).  It  can  be  distinguished  with  certainty  from 
the  sounds,  double  sounds,  and  murmurs  of  the  crural  artery  only 
when  there  exist  signs  of  aortic  or  tricuspid  insufficiency  (hence,  how 


EXAMIXATIOX  OF  THE  CIECULATORr  APPARATUS.        269 

small  is  the  diagnostic  value  of  these  phenomena  !).  Crural,  arterial. 
and  venous  sounds  may  be  combined  '^hen  there  exist  at  the  same 
time  aortic  and  tricuspid  insufficiency. 

S'ow  and  then,  even  in  health,  especially  in  thin  persons,  a  sound 
is  produced  over  the  crural  vein  by  sudden  straining  or  coughing 
(expiratory  valvular  sound  in  the  crural  vein — Friedreich). 

2.  A  continuous  murmur,  designated  as  venous  humming,  venous 
murmur,  or  buzzing,  is  often  heard  in  anamic,  and  especially  in 
chlorotic,  patients,  but  sometimes  also  in  many  healthy  persons,  over 
the  jugular  veins.  It  is  usually  louder  on  the  right  side.  It  sounds 
like  a  regular  bumming  or  a  very  fine  v^hizzing  or  like  the  humming 
of  a  top.  If  it  is  very  marked  it  can  also  be  felt.  The  murmur  is 
caused  by  the  whirl  in  the  blood  as  it  flows  fi'om  the  narrow  jugular 
into  its  wider  bulb.  The  whirls  are  the  more  marked,  the  more  rapid 
the  stream  :  and  hence  the  murmur  becomes  louder  in  deep  inspiration, 
and  for  the  same  reason  it  is  generally  louder  in  the  upright  position. 
than  when  lying  down.  And  likewise  it  is  not  infrequently  louder  in 
the  diastole  than  in  the  systole  of  the  heart.  Also,  the  predominance 
of  the  right  jugular  over  the  left  is  explained  by  the  difference  in  the 
rapidity  of  the  current  caused  by  the  different  shape  of  opening  into 
the  cava  (see  above,  p.  265).  This  murmur  will  be  increased  by  slight 
compression,  as  may  be  produced  by  the  stethoscope  or  by  turning 
the  head  to  the  opposite  side.  This  latter  effect  comes  from  the 
tension  of  the  fascia  colli,  and  probably  also  from  the  contraction  of 
the  omo-hyoideus  muscle. 

As  to  what  the  occurrence  of  this  murmur  meaus  we  must  rest  upon 
the  old  idea  that  it  chiefly  occurs  with  anaemic  and  especially  chlorotic 
patients.  Friedreich's  claim  that  it  is  more  marked  in  these  cases, 
while  in  health  it  is  usuallv  onlv  to  be  heard  as  a  soft  hummino-, 
seems  to  me  to  be  very  far-fetched.  Strictly  speaking,  no  diagnostic 
importance  is  to  be  attached  to  this  phenomenon. 

Similar  murmurs  occur  exceptionally  in  other  veins,  and  it  is  to  be 
noted,  almost  exclusively  in  anaemia ;  thus  in  the  large  veins  of  the 
extremities  and  also  in  the  intrathoracic  trunks.  Here  the  murmur 
is  always  much  stronger  during  the  heart's  diastole  and  can  thus 
appear  to  be  interi'upted.  It  has  already  been  mentioned  that  Sahli 
declared  the  angemic  heart-murmurs  to  be  in  part  propagated  from 
the  venous  trunks  in  the  chest.  ' 


270  SPECIAL  DIAGNOSIS. 

Examination  of  the  Blood. 

preliminaey  remarks. 

In  health  the  entire  quantity  of  blood  in  the  body  amounts  to  about 
one-thirteenth  of  its  weight.  At  the  bedside  we  can  in  no  way  reach 
an  approximation  of  the  quantity  of  the  blood,  although  it  is  evident 
that  the  capacity  of  the  arteries  (assuming  that  there  is  an  equal  pro- 
portion of  blood  in  the  circulation)  must  in  general  determine  the 
total  quantity  of  blood.  But  the  loss  arising  from  this  defect  in  our 
methods  of  examination  is  only  very  small,  because,  according  to  our 
present  knowledge,  the  quantity  of  the  blood  is  affected  in  a  way  that 
is  characteristic  and  understood  by  us  only  in  isolated  conditions,  as 
for  instance,  immediately  after  loss  of  blood,  with  extensive  watery 
discharges,  as  in  Asiatic  cholera  and  in  severe  diarrhoea,  especially  in 
children. 

On  the  other  hand,  according  to  our  present  knowledge  of  path- 
ology, and  our  methods  of  examination,  there  are  a  number  of  condi- 
tions of  the  blood  which  relate  to  its  morphological  constituents  or 
morphological  admixtures,  which  are,  as  also  the  amount  of  haemo- 
globin, and  certain  relations  of  this  substance  with  0,  COj,  etc.,  of 
the  greatest  importance  in  recognizing  certain  diseases.  There  are 
some  less  important  diagnostic  chemical  departures  from  the  normal. 

Besides  the  inspection  of  the  skin,  which  is  not  entirely  without  value, 
the  methods  which  chiefly  come  into  consideration  are :  the  examina- 
tion of  a  drop  of  blood  with  the  naked  eye,  spectroscopic  examination, 
and  that  which  is  made  with  certain  apparatus  for  approximative 
determination  of  the  intensity  of  the  color  (amount  of  haemoglobin). 

1.   Color  and  Spectroscopic  Character  of  the  Blood. 

Blood  taken  directly  from  a  healthy  person  is  of  a  recognized  color ; 
if  arterial  it  is  brighter,  rich  in  oxygen,  that  is,  rich  in  oxyhgemo- 
globin.  If  venous,  it  is  darker ;  if  bluish-red,  it  is  poor  in  oxygen. 
The  marked  deficiency  of  oxygen  in  the  blood  of  a  person  suffering 
from  dyspnoea  or  venous  engorgement,  or  both,  makes  the  blood  very 
dark.  In  carbonic  acid  poisoning  the  blood  is  bright  cherry-red ; 
from  chlorate  of  potash,  anilin,  and  in  severe  poisoning  by  hydro- 


EXAMIXATJOX  OF  THE  CIRCULATOR F  APPARATUS.        271 

cyanic  acid  and  nitrobenzole  it  is  brownish-red  or  chocolate  color.  In 
severe  anaemia  and  chlorosis  (hydremia)  the  blood  is  watery  ;  in 
marked  leukaemia  it  looks  a  peculiar  whitish  red  as  if  mixed  with 
milk,  or  chocolate  color. 

These  changes  in  the  color  of  the  blood  all  have  an  effect  upon  the 
color  of  the  patient's  skin,  as  has  partly  already  been  mentioned. 
Hence  patients  with  carbonic  acid  poisoning  look  strikingly  rosy, 
while  in  poisoning  with  chlorate  of  potash,  anilin,  and  nitrobenzole 
the  skin  and  mucous  membrane  is  a  peculiar  grayish  blue  or  black 
color.  These  discolorations  of  the  skin,  as  well  as  the  differences 
in  the  color  of  a  drop  of  blood  obtained  by  pricking  Avith  a  needle, 
have  too  little  distinction  to  be  directly  of  diagnostic  use.  But, 
especially  with  regard  to  the  poisons  that  have  been  mentioned, 
if  they  are  recognized  as  unusual,  they  demand  that  a  timely 
and  thorough  examination  of  the  blood  be  made  by  the  spectroscope 
or  microscope.  In  this  lies  the  great  value  of  a  knowledge  of  these 
discolorations. 

For  recognizing  haemoglobinsemia  (from  the  haemoglobin  that 
appears  in  solution  in  the  serum  of  the  blood  originating  from  the 
red  blood-corpuscles)  it  is  necessary  to  employ  a  wet  cupping-glass. 
The  blood  thus  withdrawn  is  allowed  to  stand  covered  for  twenty-four 
hours,  if  possible  in  an  ice  chest,  and  then  the  serum,  separated  from 
the  coagulum,  is  to  be  examined.  That  from  normal  blood  is  yellow, 
in  hgemoglobinaemia  it  is  rubine-red,  and  in  the  spectroscope  gives 
the  bands  of  oxyhsemoglobin  (see  below). 

Approximative  determination  of  the  amount  of  haemoglobin  :  A 
diminution  in  the  amount  of  the  haemoglobin  may  be  conditioned 
upon  a  diminished  number  of  red  corpuscles  or  upon  a  decrease  in  the 
amount  in  single  corpuscles,  or  upon  both  (see  below).  It  is  recog- 
nized by  the  paleness,  and  if  the  loss  be  very  great,  the  practised  eye 
recognizes  it  by  the  clear  watery  look  of  a  drop  of  blood.  A  variety 
of  apparatus,  called  haemochromometer,  has  been  devised  for  deter- 
mining this  condition  (Quincke,  Bizzozero),  but  recently  these  have 
been  surpassed  in  simplicity  and  utility  by  the  haemometer  of  Fleischl, 
The  principle  of  this  is  as  follows  : 

A  certain  very  small  quantity  of  blood  (obtained  by  a  prick)  is 
thinned  by  a  definite  quantity  of  water,  and  then  by  lamp  or  gaslight 
the  color  of  this  mixture  is  compared  with  the  color  of  a  glass  wedge 


272  SPECIAL  DIAGNOSIS. 

which  has  been  colored  with  Cassias'  gold  purple  and  carries  a 
movable  scale.  Upon  this  scale  the  figure  100  corresponds  with  the 
intensity  of  color  of  a  mixture  of  normal  blood.  Material  that  has 
less  intensity  has  the  numbers  90,  80,  etc.,  down  to  10,  thus  giving 
directly  the  percentage  relation  of  the  mixture  of  blood  that  is  being 
examined  to  that  of  normal  blood  with  reference  to  the  quantity  of 
hsemoglobin.  Thus  90  indicates,  if  the  mixture  of  blood  has  been 
properly  prepared  and  corresponds  in  color  with  the  color  of  the  glass 
wedge  at  that  point  of  the  scale,  that  this  blood  contains  only  ninety 
per  centum  of  normal  quantity  of  hsemoglobin. 

But  the  determination  of  the  exact  quantity  of  hsemoglobin  can 
only  be  made  by  quantitative  spectrum  analysis  (K.  Vierordt).  It 
would  exceed  the  limits  of  this  book  to  give  a  description  of  the 
method  of  procedure. 

Spectroscopic  condition  of  the  Mood.  In  certain  cases  its  examin- 
ation has  decided  significance.  Recently  it  has  been  rendered  very 
much  more  easy  by  very  practical  clinical  and  uncomplicated  apparatus, 
of  which  we  may  mention  the  spectroscope  devised  by  Desaga  (Heidel- 
berg), and  still  more  recently  Bering's  very  cheap  spectroscope  without 
lenses.  According  to  our  own  experience  and  also  the  opinion  of 
Jaksch,  the  latter  after  a  little  practice  is  entirely  satisfactory  for 
clinical  purposes. 

In  three  classes  of  cases  the  spectroscopic  examination  of  the  blood 
gives  a  valuable  result :  in  hsemoglobinsemia  there  is  no  doubt  about  the 
presence  of  the  coloring  matter  of  the  blood  in  the  serum  (see  previous 
page)  if  the  serum  shows  the  absorption  band  of  oxyhsemoglobin  ;  one 
in  yellow  near  green  (close  to  D,  Frauenhofer),  and  one  in  green  near 
the  former,  between  D  and  E.  Moreover,  in  carbonic  oxide  poisoning 
there  appear  in  the  blood  two  absorption-bands  which  are  very  near 
the  two  above  mentioned,  only  a  little  nearer  the  violet  line,  and 
hence  they  may  be  confounded  with  them,  but  they  are  very  distinctly 
separated  from  bands  of  oxyhsemoglobin  in  that  they  do  not  disappear 
on  the  addition  of  ammonium  sulphate  (since  carbonic  oxyhsemoglobin 
is  not  thus  reduced). 

Lastly,  it  has  recently  been  discovered  that  in  poisoning  with 
chlorate  of  potash  methsemoglobin  occurs  in  the  blood  m  the  living 
organism.  In  acid  and  neutral  solutions  this  causes  an  absorption- 
band  in  yellow  (between  C  and  D,  besides  three  others  more  faint). 


EXAMINATION  OF  THE   CIRCULATORS  APPARATUS.  273 

which  coincide  with  that  of  hsematin,  but  which  are  distinguished 
from  it  in  that  upon  the  addition  of  ammonium  sulphate  it  first 
gives  place  to  the  absorption-bands  of  oxyhsemoglobin,  then  to  that 
of  0-free  haemoglobin  (a  broader  band  from  D  almost  to  E  in  green 
and  yellow).  In  alkaline  solution,  methsemoglobin  shows  a  narrow 
band  in  yellow  near  to  D,  and  one  in  yellow-green  and  green. 

There  are  still  other  changes  in  the  blood  partly  relating  to  its 
color  and  partly  relating  to  its  behavior  in  the  spectrum,  when  animals 
are  poisoned,  but  they  do  not  seem  to  require  mention  in  this  book. 

2.  Microscopic  Examination  of  the  Blood. 

3Iode  of  procedure.  When  we  wish  to  examine  a  patient's  blood 
we  first  clean  an  object-glass  and  a  cover  as  carefully  as  possible. 
Then  cleaning  the  tip  of  the  finger  with  water  or  a  |^  per  cent,  solu- 
tion of  salt  as  carefully  as  possible,  we  puncture  the  finger-tip  with 
a  clean  needle  and  allow  a  drop  of  blood  as  it  escapes  to  fall  upon  the 
object-glass  and  without  pressure  cover  it,  or  we  move  the  cover 
lightly,  without  disturbing  the  finger,  over  the  escaping  blood,  and 
then  immediately  very  cautiously  place  it  upon  the  object-glass.  It 
is  not  advisable  to  squeeze  the  patient's  finger  in  order  to  force  the 
blood  out. 

In  examining  for  microorganisms  all  instruments  or  apparatus  must 
be  especially  cleaned,  and  the  finger  scrubbed  with  soap  and  a  brush, 
then  with  alcohol  and  ether.  According  to  the  special  object  of  the 
examination  we  employ  a  magnifying  power  of  from  300  to  700 
<liameters. 

If,  instead  of  the  finger,  we  prick  the  lobe  of  the  ear,  it  is  just  as 
well,  and  the  whole  proceeding  is  much  less  painful  to  the  patient. 

The  normal  structures  of  the  blood  consist  of  red  and  white  blood- 
corpuscles,  and  blood-plates.  Clinically  the  latter  of  these  have  pre- 
viously had  no  interest.  The  pathological  conditions  that  are  recog- 
nizable by  the  microscope  may  be  divided  into  alterations  in  the 
number  or  appearance  of  the  blood- cells,  and  into  foreign  substances, 
as  microorganisns. 

In  general,  we  again  distinguish  the  changes  in  the  number  and 
character  of  the  blood-corpuscles  with  reference  to  diminution  of  the 
red  corpuscles  (oligocythsemia)  and  changes  in  the  structure  and  size 

18 


27-4  SPECIAL  DIAGNOSIS. 

of  the  red  corpuscles  (poikilocjthsemia  and  raicrocytlisemia).  But 
these  forms  often  pass  into  each  other. 

1.  Oligocythcemia^  diminution  in  the  number  of  red  corpuscles,  is 
the  change  which  takes  place  in  anaemia  (not  in  chlorosis).  If  very 
marked,  it  is  even  recognized  by  the  watery  appearance  of  a  drop  of 
blood.  At  all  events,  by  the  practised  eye  it  may  be  recognized 
"without  farther  examination  of  the  ordinary  microscopical  preparation 
(although  very  little  reliance  can  be  placed  upon  such  a  superficial 
examination).  For  exactly  determining  the  number  of  blood-corpuscles 
we  employ  an  apparatus  devised  for  counting  the  corpuscles  in  a  given 
quantity  of  blood. 

It  is  in  the  first  place  to  be  remarked  that  counting  of  the  red 
corpuscles  is  very  seldom  absolutely  necessary  for  making  a  diagnosis 
of  the  diiferent  forms  of  ansemia  (of  which  see  below),  but  it  may  be  of 
great  value  in  judging  of  the  course  of  a  given  disease,  especially  as 
regards  the  effect  of  treatment. 

The  Thoma-Zeiss  apparatus  for  counting  the  number  of  corpuscles 
is  the  best  of  all  those  now  in  use.  It  consists  of  a  mixer  and  a 
Hayem's  counting  chamber. 

Q^he  mixer  serves  to  distribute  the  blood  in  as  equal  a  manner  as 
possible,  a  very  important  point.  For  thinning  the  blood  a  3  per 
cent,  solution  of  salt  is  recommended.  The  mixer  is  a  kind  of 
measuring  pipette  with  a  very  fine  canal,  and  with  a  spherical 
enlargement  containing  a  little  glass  ball.  The  portion  of  the'  tube 
below  the  cavity  has  the  marks  0.5  and  1.0.  Just  above  the  cavity 
is  the  mark  101.  The  first  two  marks  are  those  to  which  the  blood, 
directly  after  it  has  been  drawn  from  the  finger,  is  sucked.  If  we 
wish  a  mixture  of  1  to  200  we  draw  it  up  to  0.5;  if  a  mixture  of 
1  to  100  to  1.0.  In  both  cases  we  wash  off  the  blood  clinging  to  the 
point,  and  draw  in  a  3  per  cent,  solution  of  salt  to  101.  Then 
the  mixer  is  shaken  several  times  so  that  the  glass  ball  equally  mixes 
its  contents.  We  next  expel  the  contents  of  the  fine  tube,  which 
consist  of  salt  solution,  after  which  we  fill  from  the  mixture  a 
Hayem's  counting  chamber.  This  consists  of  an  object-glass  with  a 
circular  excavation;  it  is  a  space  exactly^  mm.  deep,  the  floor  of 
which  is  divided  into  microscopic  squares,  whose  sides  are  2^0-  mm. 
long.     The  cubic  capacity  of  the  space  over  each  square  is  -^-^  X  ^V 


10 


c.mm.  =  i-7r?wr  c.mm. 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.        £75 

Into  this  cavity  some  of  the  blood-mixture  is  blown  and  then 
covered  with  a  glass  cover  after  carefully  expelling  any  air  bubbles. 

After  waiting  a  moment  in  order  that  the  blood-corpuscles  may  as 
far  as  possible  equally  distribute  themselves,  we  magnify  it  about  50 
diameters  and  count  the  number  of  corpuscles  in  the  larger  number 
of  the  above-named  squares,  and  thus  obtain  an  average  of  the 
contents  of  say  sixteen  of  them.  The  oftener  these  sixteen  squares 
are  counted,  the  greater  will  be  the  accuracy  of  the  result.  We  can 
calculate  the  number  of  corpuscles  in  a  cubic  millimetre  from  the 
proportions  of  the  mixture  and  the  cubic  contents  of  the  squares,  as 
given  above. 

Immediately  after  use,  the  mixer  must  be  most  carefully  washed 
■with  Avater,  alcohol  and  ether. 

Normally,  in  a  cubic  millimetre  of  human  blood,  there  are  in  the 
male  about  five  million,  in  the  female  about  four  and  a  half  million 
red  corpuscles  (C.  Yierordt,  Laache).  We  may  only  positively  affirm 
that  there  is  a  pathological  diminution  when,  examining  a  case  for 
the  first  time,  the  enumeration  gives  half  of  the  number  or  less. 
The  least  quantity  observed  in  disease  is  about  400,000  to  the  cubic 
millimetre. 

Besides  diminution  in  the  number  of  red  corpuscles,  in  anaemia 
(hydrsemia)  we  observe  the  following :  1.  They  manifest  diminished 
or  even  no  tendency  to  the  formation  of  rouleaux^  which  is  a  well- 
known  peculiarity  of  normal  blood.  2.  Star  forms,  mulberry  forms, 
which  are  also  usual  in  normal  blood  as  soon  as  it  is  withdrawn, 
occur  seldom  or  not  at  all.  3.  The  red  corpuscles  are  paler  in  simple 
anaemia  (very  markedly  so  in  chlorosis),  on  account  of  the  diminished 
amount  of  haemoglobin.  The  opposite  condition  is  not  infrequent 
in  poikilo-  and  micro-cythaemia  (which  see).  4.  In  a  certain  pro- 
portion of  cases  there  occurs  a  slight  alteration  in  the  form  and 
size  of  the  red  corpuscles,  as  referred  to  under  3.  5.  The  white 
corpuscles  are,  in  proportion  to  the  red,  somewhat  increased  (relative 
leucocythsemia) 

Oligocythaemia  is  always  connected  with  diminished  amount  of 
haemoglobin  in  the  blood,  whether  there  is  a  diminution  in  the  number 
of  the  red  corpuscles  or  the  individual  corpuscles  are  paler.  The 
diseases  in  which  both  conditions  exist  are  the  different  forms  of 
anaemia,  pernicious  anaemia,  leucaemia.     On  the  other  hand,  only  a 


276  SPECIAL  DIAGNOSIS. 

diminished  quantity  of  hsemoglobin  in  the  blood,  that  is  to  saj,  no 
notable  diminution  in  the  number  of  red  corpuscles,  occurs  in 
chlorosis.  In  observing  the  progress  of  the  first-named  diseases  we 
must  make  an  enumeration  and  examine  with  reference  to  the  amount 
of  haemoglobin,  while  in  chlorosis  it  is  only  necessary  to  examine  for 
the  latter.  In  the  former  case  the  number  of  red  corpuscles  and  the 
haemoglobin  seem  to  go  hand  in  hand.  Hence  it  seems  to  me  that, 
especially  on  account  of  its  simplicity  and  its  approximate  accuracy, 
Fleischl's  hsemometer  may  be  very  strongly  recommended  to  physicians 
for  examining  the  color  of  the  blood  in  the  course  of  an  anaemia 
(strictly  speaking,  chlorosis),  thus  answering  in  a  great  majority  of 
cases,  on  account  of  the  particular  care  which  the  enumeration 
requires,  unless  there  should  be  some  indication  for  counting  the 
corpuscles. 

2.  Alterations  in  the  size  and  form  of  the  red  corpuscles.  Formerly 
this  was,  in  its  totality,  considered  as  a  diagnostic  sign  of  pernicious 
anaemia.  Now  we  know  that  there  are  other  conditions  that  accom- 
pany such  variations.  The  simplest  way  of  determining  the  size  is 
to  compare  a  preparation  of  blood  with  that  of  a  healthy  person  (the 
examiner  himself).  The  normal  diameter  of  red  blood-corpuscles  is 
7.7  to  8  /^  [i.  e.,  about  3-7^00"  ^^  ^^  inch]. 

Microcythsemia.  By  this  we  understand  the  occurrence  of  forms 
containing  haemoglobin,  which  are  smaller  than  red  blood-corpuscles, 
in  which  the  form  is  nearly  or  quite  perfect,  or,  if  they  are  very 
small,  they  are  simply  globular.  We  see  the  former  in  the  new 
formations  of  blood  after  hemorrhages,  and  also  in  all  kinds  of  ansemia. 
They  are  probably  young  red  corpuscles.  The  latter — microcytes, 
strictly  so-called — occur  especially  frequently  in  pernicious  anaemia, 
and  also  in  all  other  forms  of  ansemia.  The  supposition  that  they  are 
formed  upon  the  glass  slide  is  possibly  correct,  because  they  may  even 
be  found  in  normal  blood  when  the  preparation  contains  air,  is  pressed, 
or  is  old.  I  have  never  seen  them  when  examining  a  perfectly 
fresh,  otherwise  normal  preparation  of  blood,  except  at  the  border  (the 
effect  of  air). 

Macrocytes — abnormally  large  red  corpuscles,  besides  those  of 
normal  size  and  very  small  ones — occur  in  individual  cases  of  marked 
and  simple  anaemia,  but  especially  in  pernicious  anaemia.  This 
disease  must  always  be  suspected  when  they  are  present.     Corpuscles 


EXAMINATION  OF  THE  CIRCULATORY  APPARATUS.        277 

that  are  larger  than  normal  are  almost  always  also  poikilocytes,  like 
the  following : 

Poikilocytes,  strictly  speaking,  are  red  corpuscles  changed  in  form. 
They  may  assume  the  greatest  variety  of  forms — club,  biscuit,  pear, 
flask,  and  drum-stick  are  the  most  usual  forms.  In  many  ways 
poikilocytes  correspond  to  enlarged  red  corpuscles.  In  individual 
cases  they  exhibit  amoeboid  movements.  In  a  wider  sense  we  employ 
the  expression  poikilocytosis  to  a  mixture  of  such  forms  with  micro- 
cytes  and  macrocytes,  which  are  almost  always  present. 

Fig.  76. 


d 

Poikilo-,  macro-,  microaytosis  (as  represented  by  tlie  letters  d,  h,  c\  a,  normal  blood- 
corpuscle;  e,  product  of  decomposition  of  a  red  blood -corpuscle  ;  /,  nucleated  red  blood- 
corpuscle  (marked  ansemia).     (After  Quinckk.) 

We  must  avoid  confounding  with  them  the  mulberry  and  thorn- 
apple  forms,  which  occur  normally,  or  mechanical  or  chemical  products, 
by  using  the  greatest  care  in  making-  the  preparations  and  then  imme- 
diately examining  them. 

Poikilocytosis  is  not  at  all  a  pathognomonic  symptom  of  pernicious 
anaemia,  although  in  other  forms  of  anaemia  it  does  not  occur  so 
regularly  and  in  so  marked  a  degree  as  in  pernicious  anaemia.  It 
may  occur  Avith  any  severe  form  of  anaemia  and  cachexia,  as  in  tape- 
worm, or  cancer-cachexia. 

As  a  matter  of  course,  all  these  changes  in  the  red  corpuscles 
usually  very  notably  accompany  diminution  in  their  number  and  of 
the  amount  of  haemoglobin.  Hence,  as  has  already  been  mentioned, 
the  amount  of  haemoglobin  in  single  blood-corpuscles  is  not  infre- 
quently increased. 


278 


SPECIAL   DIAGNOSIS. 


3.  Increase  of  the  white  hlood-corpuseles  {leakcemia,  leucocytosis). 
The  proportion  of  white  blood-corpuscles  to  the  red  in  normal  blood, 
drawn  by  pricking  the  finger,  if  Ave  take  the  average  of  the  reported 
observations,  is  about  1 :  400  to  1  :  700,  which  is  a  considerable 
variation. 

Where  this  proportion  varies  temporarily  and  slightly  in  favor  of 
the  white  corpuscles,  we  designate  the  condition  as  leucocytosis ;  if  it 
is  long  continued  and  very  marked,  as  leukaemia. 

Ordinarily  we  can  easily  distinguish  at  the  first  glance  between 
these  two  conditions,  sinco  leukgemia  is  generally  accompanied  with  a 
very  marked  increase,  and  leucocytosis  with  but  a  slight  increase  of 
the  white  cells.  Hence,  we  rarely  have  cases  that  are  on  the  border 
between  the  two. 

Fig.  77. 


Blood  of  leukaemia.     (After  Fuxkk.) 


During  digestion,  leucocytosis  is  observed  as  a  physiological  condi- 
tion. It  is  also  seen  in  acute  infectious  diseases,  especially  in  typhoid 
fever  and  in  relapsing  fever,  malignant  pustule,  etc.  We  have 
inflammatory  leucocytosis  in  swelling  of  the  lymphatic  glands  from 
inflammation  of  all  kinds,  especially  in  erysipelas.  Lastly,  we  meet 
with  cachectic  or  hydrsemic  leucocytosis  in  all  forms  of  anaemia,  and 
this  may  be  either  relative,  dependent  upon  a  diminution  of  the  red 
corpuscles,  or,  as  enumeration  shows,  it  may  be  absolute.  In  the 
latter  case,  it  is  explained  by  the  undoubted  acceleration  of  the 
lymph-current  in  consequence  of  hydraemia. 


EXAMINAriON  OF  THE  CIRCULATORY  APPARATUS.        279 

Under  the  microscope,  leukaemia  is  manifest  in  that  usually  there  is 
a  remarkable  increase  in  the  white  corpuscles.  The  proportion  of 
white  to  red  corpuscles  is  as  1  to  10  ;  manj^  writers  think  that  when 
the  proportion  i«  more  than  1  to  20  we  have  the  condition  of 
leukaemia.  In  extreme  cases,  which  are  rare,  the  number  of  red  and 
A>hite  corpuscles  becomes  about  equal. 

At  any  rate,  the  number  of  red  corpuscles  is  always  diminished: 
Jaksch  found  the  average  ,of  a  number  of  cases  to  be  two  to  three 
million  cells  (red  and  white)  in  a  cubic  millimetre  of  blood.  The  size 
of  the  white  corpuscles  usually  remains  normal;  but  very  often  re- 
markably large  leucocytes  are  found,  some  of  which  have  strikingly 
large  nuclei.  Moreover,  we  sometimes  find  nucleated  red  corpuscles 
(probably  transition  forms  from  the  white  to  red).  The  red  corpuscles 
often  have  the  forms  of  poikilocytosis.  Ehrlich  found  a«-emarkable 
behavior  of  leucocytes — that  is,  their  protoplasmic  granules — in  the 
presence  of  certain  aniline  colors.  His  most  important  result  is  the  dis- 
covery that  only  in  leuktemia  are  there  found  in  the  blood  white  cells 
called  eosinophile — that  is,  that  are  distinctly  colored  with  eosin.  In 
doubtful  cases  this  fact  would  seem  to  be  useful  in  diagnosing  leukaemia.^ 

Ehrlich  dries  a  preparation  upon  a  covering  glass,  as  thin  as  possible, 
in  the  air  or  exsiccator,  heats  it  for  ten  to  twelve  hours  in  a  drying 
chamber  at  1'20°-130°  C,  and  quickly  stains  it  with  eosin-glycerin. 
Then  he  washes  it  with  water,  and  mounts  it  dry  in  Canada  balsam. 

Opinion  is  divided  as  to  whether  it  is  possible  to  recognize  the 
different  pathological,  anatomical,  or  clinical  forms  of  leuksemia^-Jjy 
the  condition  of  the  blood — that  is,  to  discriminate  whether  the  leu- 
kaemia exists  by  participation  with  lymph-glands,  the  spleen,  medulla 
of  the  bones  (lymphatic,  splenic,  myelogenic  leukaemia).  It  seems 
true  that  the  above-mentioned  transition-forms  between  red  and  white 
blood-corpuscles  point  to  alterations  in  the  medulla  of  the  bones. 
Moreover,  many  think  that  the  small  cells  are  more  connected  with 
the  lymph-glands  and  the  large  ones  with  the  spleen. 

In  extremely  rare  cases  of  leukaemia,  crystals  are  found  in  the  blood 
(Charcot):  they  are  colorless,  shining,  long  octahedral,  like  Charcot's 
crystals  found  in  the  stools  and  expectoration,  or  they  are  identical 
with  them. 

1  According  to  the  investigations  of  Jliiller  and  Rieder,  tlie  eosinophile  cells  sho\v 
that  in  leukseniia  the  boae-iuaiTOW  is  primarily  affected. — TRANSLATOR. 


"280  SPECIAL   DIAGNOSIS. 

4.  Abnormal  additions  to  the  blood.  Of  these  we  first  mention 
melaneemia  and  lipsemia. 

Melancemia  occurs  directly  after  severe  attacks  of  malaria  and  in 
malarial  disease.  We  sometimes  find,  swimming  free  in  the  blood, 
brownish -black  or  yellow-brown  lumps  and  granules,  or,  also,  white 
blood-corpuscles  filled  with  such  granules.  They  result  from  breaking 
up  of  red  corpuscles. 

By  lipcemia  we  understand  the  occurrence  of  extremely  fine  drops 
of  fat  in  the  blood,  as  in  drunkards,  in  diabetes,  and  in  chyluria ;  but 
they  are  also  sometimes  seen  in  health. 

In  recent  times  we  have  learned  to  recognize  microorganisms  as 
most  important  additions  to  human  blood.  They  are  exclusively 
schizomycetes. 

Fig.  78. 


Anthrax  bacilli  in  the  arterial  human  blood  (fuchsine-staining.  Ziess's  homogeneous 
immersion  lens  xj.  eye  piece  4,  camera  lucida,  magnified  about  1000  diameters).  The 
white  line  in  the  middle  of  the  bacilli  indicates  only  reflections.  Prepared  by  Dr. 
Freimuth  in  Danzig. 

Anthrax  bacilli  in  the  blood  have  been  repeatedly  found  in  infec- 
tion by  anthrax,  although  always  in  moderate  quantity.  The  defect 
in  the  microscopical  proof  does  not  exclude,  however,  a  general  in- 
fection:   a  test  by  inoculating  mice  may,  however,  succeed. 

We  may  often  have  single  bacilli  of  anthrax  occurring  together, 
not  threads ;  spores  may  be  entirely  wanting.    The  bacilli  are  recog- 


EXAMINATION  OF  THE   CIRCULATORY  APPARATUS. 


281 


nized,  without  staining,  as  tolerably  thick  rods,  as  long  as,  or  twice 

the  diameter   of,  a  red   blood-corpuscle. 

below. 


Regarding   staining, 


see 


c8o^oR#      o 


o 


.QV 


Spirillum  recurrens  in  the  blood.     (After  Jaksch.) 


The  first  microorganisms  that  were  seen  in  the  blood  were  the  spi- 
rillum recurrens  (Obermeier).  We  find  them  during  an  attack  of 
recurrent  fever.  They  disappear  shortly  before  the  decline  of  the 
fever.  By  careful  examination  they  can  always  be  demonstrated, 
although  sometimes  there  are  only  a  few  of  them. 

In  a  fresh  drop  of  blood  they  appear  (Hartnack  8,  Zeiss  F)  as 
extremely  fine  threads,  about  five  times  as  long  as  the  diameter  of  a 
red  corpuscle,  with  extremely  active  spiral,  serpentine  motion.  They 
occur  either  singly  or  several  close  together,  sometimes  lying  together 
like  a  group  of  rats'  tails.  I  have  very  often  first  seen  them  near 
white  blood-corpuscles.  The  white  or  red  corpuscle  against  which  it 
lies  is  usually  set  slightly  in  motion  by  the  microbe,  and  hence  we 
find  them  there  first.  Moreover,  there  often  occurs  in  the  blood  slight 
leukocytosis ;  also,  we  sometimes  meet  with  shining  granules  (elemen- 
tary granules  ?  spores  ?).  As  to  staining,  which,  after  a  little  practice, 
is  not  necessary,  see  below. 

Tubercle  bacillus  exists  in  the  blood  as  evidence  of  miliary  tuber- 
culosis. But  in  this  disease  we  may  lack  this  proof.  With  the 
exception  of  one  case  observed  by  Jacksch,  it  always  occurs  quite 
isolated.  A  special  treatment  is  required  for  obtaining  this  microbe. 
We  arrange  a  thin  layer  of  blood  upon  the  glass  cover  just  as  we  do 
a  preparation  of  sputum  (see  Sputum). 

Typhus  abdominalis  bacilli  have  in  several  cases  been  found  in  the 


282  SPECIAL   DIAGNOSIS. 

blood  as  short  (one-third  the  diameter  of  the  red  corpuscle),  thick 
clubs,  rounded  at  the  end.  See  examination  of  the  Stools  (for  stain- 
ing, see  below). 

The  bacilli  of  glanders  are,  in  general,  a  little  longer  than  the  pre- 
ceding, but  considerably  slimmer.  They  have  likewise  been  found  a 
number  of  times  in  the  blood  of  this  disease.  It  is  necessary  to  stain 
them  (see  below). 

[Since  the  publication  of  the  first  edition  of  this  work  the  Plas- 
modium malarice  (Laveran)  has  been  studied  by  many  observers 
(Marchiafava,  Colli,  Canalis,  v.  Jaksch,  Osier,  Shattuck,  Dock,  and 
many  others).  All  concur  in  stating  that  certain  organisms  are  found 
in  the  blood  in  every  genuine  case  of  malarial  fever.  Doubtful  cases 
can  be  differentiated  by  examining  the  blood  for  them,  and  a  pos- 
itive diagnosis  made  from  their  absence  or  presence.  Corresponding 
with  the  different  clinical  features  of  malarial  fevers,  there  are  found 
three  different  types  of  malarial  parasites  :  those  of  tertian,  of  quar- 
tan, and  of  the  atypical  and  irregular  fevers.]  They  are  protoplas- 
mic bodies,  within  [and  without]  the  red  corpuscles,  which  can  be 
stained  by  methylene-blue.  No  cultures  of  them  have  yet  been 
obtained. 

The  greatest  care  and  cleanliness  are  necessary  in  arranging  a 
preparation  of  blood  for  microscopic  examination  for  microorganisms, 
although  the  minutiae  of  disinfection  and  sterilization,  as  in  preparing 
for  culture,  are  not  required.  In  malignant  pustule  and/e&m  reeurrens 
staining  can  be  dispensed  with.  When  it  is  necessary  to  stain  a 
preparation,  it  is  prepared  by  drying  a  small  drop  of  blood  which  has 
been  spread  out  and  made  as  thin  as  possible  by  pressing  two  covers 
together.  Then  they  are  separated,  allowed  to  dry  in  the  air,  and 
afterward  passed  two  or  three  times  through  the  flame  of  a  spirit-lamp 
or  a  Bunsen's  burner.  If,  now,  we  wish  to  examine  for  tubercle 
bacilli,  a  special  treatment  is  necessary,  as  has  already  been  described 
under  Sputum.  For  other  microorganisms  we  stain  with  basic  aniliiie 
colors  (vesuvine,  fuchsine,  particularly  methylene-blue,  etc.),  and  then 
carefully  rinse  and  examine  in  water,  or,  after  drying,  in  Canada  balsam. 
The  staining  is  much  more  beautiful  if  we  first  briefly  dip  them  in 
gentian-violet-aniline  water  (see  al)Ove  under  Sputum),  and  then  stain 
them   a   few   minutes  in    Gram's   iodine-iodide-of-potassium   solution 


EXAMINATION  OF  THE   CIRCULATORY  APPARATUS. 


283 


(iodine  1   part,  iodide  of  potassium   2  parts,  aq.   destil.  300  parts), 
then  in  absolute  alcohol. 

Finally,  we  briefly  refer  to  two  animal  parasites  which  are  met  with 
in  the  blood,  though  they  do  not  belong  in  this  book  :  the  filaria  san- 
guinis hominis,  which  causes  haematochyluria  (in  British  India  and 
Brazil),  generally  only  found  in  the  blood  at  night-time,  and  distoma 
hcematohium  (Bilharz),  which  causes  a  kind  of  haematuria,  chiefly 
occurring  in  Egypt.     (See  under  Urine.) 


Fig.  81. 


Distoma  ha?matobium  with  eggs. 
(After  Jaksch.) 


Filaria  sanguinis  hominis. 
(After  Jaksch.) 


Chemical  Examination  of  the  Blood. — We  content  ourselves 
with  a  few  hints  regarding  this  department,  since  it  lies  almost 
entirely  outside  of  the  limits  of  diagnosis. 

Recently,  in  certain  diseases,  the  degree  of  alkalescence  of  freshly- 
drawn  blood  has  been  determined  by  various  methods,  and  it  has 
been  found  that  in  severe  anaemia,  fever,  and  diabetes  (Jaksch)  the 
alkalescence  is  considerably  diminished.  Uric  acid  in  unusual  quantity 
has  been  found  in  the  blood  in  gout. 

The  quickness  with  which  blood  coagulates  after  it  has  been  with- 
drawn varies  in  diff"erent  diseases.  In  health,  coagulation  takes  place 
in  about  nine  minutes.  It  is  slower  than  this  where  the  nutrition  is 
chronically  disturbed.    (H.  Vierordt.) 


CHAPTER    YI. 

EXAMINATION  OF  THE  DIGESTIVE  APPARATUS. 

Mouth,  Palate,  and  Pharyngeal  Cavity. 

The  inspection  of  these  parts  requires  good  illumination,  and  for  a 
portion  of  them,  in  many  cases,  a  quick  view.  Bright  daylight  is  better 
than  artificial  light.  The  mouth  is  to  be  opened  widely,  the  tongue 
protruded,  and  not  only  put  out,  but,  for  inspecting  its  borders,  turned 
from  side  to  side.  (For  examining  it  with  reference  to  paralysis,  see 
Nervous  System.)  In  order  to  inspect  the  mucous  membrane  of  the 
mouth,  v^c  turn  out  the  upper  and  lower  lips  with  the  finger,  the 
mouth  being  closed ;  then,  the  mouth  being  opened,  we  carefully  lift 
the  mucous  membrane  of  the  cheeks  from  the  back  teeth  with  a 
mouth-spatula  (made  of  ivory,  hard  rubber,  horn,  or  metal).  The 
gums  are  examined  by  opening  the  mouth  as  Avidely  as  possible  and 
holding  the  tongue  down  carefully  with  a  tongue-depressor  (a  teaspoon 
serves  very  well).  The  back  of  the  mouth  is  best  brought  into  view 
by  having  the  patient  say  distinctly  "se"  (full  elevation  of  the  soft 
palate). 

The  patient  should  be  required  to  drink  some  water,  also  to  clear 
the  throat  thoroughly  before  it  is  examined.  If  we  meet  with 
opposition,  especially  in  children,  it  is  sometimes  necessary  to  hold 
the  nose,  and  thus  compel  them  to  open  the  mouth.  When  a  child 
cries,  we  are  able  to  see  very  well  It  is  often  useful  to  cause  the 
sensation  of  strangling  by  putting  the  tongue-depressor  far  back,  and 
thus  we  are  able  to  see  the  tonsils  better — of  course,  only  for  an 
instant.  [One  learns,  by  practice,  to  take  a  very  perfect  and  com- 
plete view  of  the  whole  cavity  of  the  mouth  and  pharynx  in  this 
instant  of  strangulation,  and  then  can  carry  the  mental  picture  long 
enough  to  note  all  its  particulars.] 

But  we  must  guard  against  being  too  harsh  or  rough  with  children 
with  diphtlieria^  or  with  any  very  sick  patient.  In  diphtheria,  imme- 
(284) 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  285 

diate  death  may  follow  an  effort  at  examining  the  throat.  With  those 
who  are  unconscious,  it  is  necessary  to  cause  gagging  in  order  to 
inspect  the  posterior  part  of  the  mouth.  In  marked  cases  of  this 
character,  it  is  often  impossible  to  obtain  a  view  at  all. 

Palpation  is  only  rarely  employed  for  examining  the  tongue,  floor 
of  the  mouth  (making  counter-pressure  from  without),  the  tonsils,  or 
the  back  part  of  the  pharynx.  We  employ  the  index,  or  this  and  the 
middle  fingers,  which  have  been  carefully  washed  in  the  presence  of 
the  patient. 

The  odor  from  the  mouth  is,  in  many  cases,  important.  A  foul 
odor — -foetor  ex  ore — results  from  imperfect  cleansing  of  the  teeth, 
caries  of  the  teeth,  or  dyspepsia.  From  this  odor  we  distinguish  the 
stale,  and  at  the  same  time  foul,  fetor  from  considerable  old  deposit 
in  the  mouth  of  patients  who  are  very  ill.  If  the  sense  of  smell  is 
acute,  one  can  also  distinguish  a  slight  cadaveric  odor  upon  patients 
who  are  very  sick,  even  if  the  mouth  is  quite  clean,  and  sometimes  it 
precedes  death. 

Of  much  more  diagnostic  value  are  the  different  odors  which  we 
meet  with  in  poisoning  from  prussic  acid,  phosphorus,  alcohol,  and 
chloroform ;  but  the  two  former,  even  in  recent  cases,  may  possibly 
be  wanting.  Lastly,  we  mention  the  odor  of  fruit,  wrongly  called 
"acetone"  odor,  very  like  fresh  apples,  which  sometimes  occurs  with 
the  so-called  chloride  of  iron  reaction  of  the  urine  (see)  in  diabetes, 
especially  before  or  during  the  onset  of  diabetic  coma. 

The  lips.  With  regard  to  their  color  (pale,  cyanosed,  etc.),  we  can 
refer  to  what  has  already  been  said  when  speaking  of  the  mucous 
membrane.  Dryness  of  the  lips  is  seen  in  connection  with  dryness  of 
the  tongue  (which  see).  There  is  marked  dryness  in  severe  febrile 
diseases,  with  a  dirty  looking  crust  adherent  to  the  mucous  membrane, 
which  easily  bleeds  when  this  is  removed  (fuliginous  deposit).  Small 
cracks  (rhagades,  crevices)  are,  in  themselves,  without  significance. 
On  the  contrary,  in  children,  rhagades  are  an  important,  generally  a 
positive,  sign  of  hereditary  syphilis. 

The  teeth  and  gums.  We  must  take  both  into  consideration,  and, 
besides,  as  to  whether  the  teeth  are  sound.  In  small  children  we 
notice  whether  the  first  teeth  have  all  come ;  in  the  later  years  of 
childhood,  the  change  to  the  permanent  set. 

There  is  often  marked  caries  of  the  teeth  in   diabetes  meUitus, 


286  SPECIAL  DIAGNOSIS. 

though  it  is  very  common  without  this  disease.  A  circular  excavation 
of  the  lower  edge  of  the  upper  middle  incisor  teeth  of  the  second 
dentition  [Hutchinson's  teeth]  is  usually  a  positive,  almost  pathogno- 
monic, sign  of  congenital  syphilis  (with  catarrh  of  the  middle-ear  and 
parenchymatous  keratitis,  the  whole  forming  the  infallible  Hutchin- 
son's triad).  Imperfect  and  diseased  teeth,  interfering  with  mastica- 
tion, are  often  the  chief  cause  of  dyspepsia. 

Loosening  of  the  teeth,  and  the  gums  discolored  bluish-red,  receding 
from  the  teeth,  easily  bleeding,  and  even  inflamed,  are  important 
symptoms  of  scorbutus.  Loose  teeth,  with  moderate  swelling,  is  a 
sign  of  chronic  poisoning  with  mercury. 

A  grayish  deposit  upon  the  teeth,  and  a  gray  line  along  the  dental 
border  of  the  gums,  results  from  chronic  lead-poisoning.  In  poisoning 
by  copper,  we  have  sometimes  the  same  condition,  only  the  color  is 
greener. 

The  eruption  of  the  first  teeth  is  a  source  of  much  disturbance  in 
the  mouth  of  the  little  patients.  Occasionally  it  gives  rise  to  serious 
disturbances — diarrhoea  in  rare  cases,  epileptiform  attacks  (eclampsia 
of  children,  infantile  convulsions,  spasms  of  dentition),  also  spasm  of 
the  glottis.  Second  dentition  and  the  eruption  of  the  wisdom-teeth 
are  not  infrequently  accompanied  with  limited  or  general  oral  dis- 
turbances, sometimes  likewise  the  cause  of  abscess.  To  the  red  border 
upon  the  gum,  observed  by  Fredericq-Thompson,  which  in  young 
subjects  is  said  to  be  a  very  suspicious  sign  of  tuberculosis,  we  have 
given  careful  attention  for  a  long  time,  and  conclude  that  it  has  no 
significance. 

The  tongue.  For  paralysis  and  neurotic  atrophy  of  the  tongue,  see 
under,  the  Nervous  System. 

Enlargement  of  the  tongue,  if  slight,  is  only  to  be  determined  from 
the  indentations  on  its  borders  by  the  lower  teeth.  This  occurs  with 
the  various  forms  of  stomatitis.  Marked  enlargement  of  the  tongue 
may  be  caused  by  parenchymatous  glossitis,  tumors,  and  also  by 
severe  angina,  which  produce  venous  engorgement  of  the  tongue. 
Moreover,  there  are  very  great  individual  variations  in  the  size  of  the 
tongue. 

Circumscribed  swelling  and  hardness,  or  the  latter  alone,  are  the 
first  evidences  of  carcinomatous  or  syphilitic  formations  of  the  tongue. 
It  is  extremely  difficult  to  make  the  very  important  differential  diag- 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  287 

nosis  between  these  new  growths,  and  usually  it  can  only  be  made  by 
microscopically  examining  a  small  piece,  which  can  easily  be  removed 
from  it.     (See,  regarding  this,  in  works  upon  surgery.) 

Wounds  and  the  resulting  scars,  sometimes  accompanied  with 
swelling,  are  frequent  appearances  after  epileptic  attacks,  and  result 
from  biting  the  tongue  (see  Scars).  We  nevei-  see  the  tongue  bitten 
in  hystero-epilepsy. 

If  the  tongue  trembles  when  it  is  protruded,  or  if  it  does  so  when 
within  the  mouth,  it  is  a  valuable  sign  of  chronic  alcoholism.  This 
is  also  the  case  in  severe  fevers,  and  especially  early  in  typhus  abdomi- 
nalis  [typhoid  fever].  In  these  cases,  when  there  is  marked  herbetude, 
the  patient  often  will  not  draw  in  his  tongue  after  protruding  it  unless 
he  is  directed  to  do  so. 

The  color  of  the  tongue  is  affected  by  that  of  the  blood :  cyanosis 
affords  the  most  marked  instance  of  this.  It  is  quite  common  to  find 
local  redness  with  febrile  conditions.  It  often  goes  side  by  side  with 
the  febrile  redness  of  the  cheeks.  Mulberry  tongue  is  one  in  which 
there  is  a  decided  redness  with  swelling  of  the  papillse,  and  is  an 
important  sign  of  scarlet  fever,  which,  in  individual  cases,  may 
develop  before  the  cutaneous  eruption.  Very  often  the  coating  of 
the  tongue  conceals  the  color  of  the  mucous  membrane. 

When  the  saliva  is  glutinous  or  diminished  it  causes  the  tongue  to 
be  sticky  or  dry.  In  connection  with  dryness  of  the  throat,  febrile 
diseases  cause  thirst.  When  the  fever  is  very  high,  the  dryness  is 
often  increased  by  the  patient  keeping  his  mouth  constantly  open. 
Then  the  surface  of  the  tongue,  if  free  from  coating,  first  becomes 
horny,  then  quickly  very  smooth,  and  soon  rough  and  cracked. 

Coating  of  the  tongue,  as  a  thin  white  layer,  is  often  constant  in 
health.  When  a  tongue  which  previously  was  clean  becomes  coated, 
especially  if  thickly  coated,  it  indicates  dyspepsia.  There  is  very 
marked  coating  of  the  tongue  in  severe  acute  and  chronic  diseases  of 
the  stomach  and  with  the  dyspepsia  of  fever.  With  the  latter,  it  is 
often  discolored  brownish-red  from  small  hemorrhages  of  the  mucous 
membrane.  When  there  is  great  dryness  of  the  tongue,  it  becomes 
crusty  and  adheres  so  closely  that  when  removed  the  mucous  membrane 
bleeds.  Articles  of  diet  may  cause  temporary  coating,  or  they  may 
color  the  coating  that  is  already  there  (milk,  cocoa,  coffee,  etc.). 

A  thick  white — often,  also,  a  discolored — coating  on  the  tongue 
may  depend  upon  the  development  of  thrush  (Oidium  albicans).     In 


288  SPECIAL  DIAGNOSIS. 

very  pronounced  cases  it  forms  separate  small  tufts  about  the  size  of 
a  millet-seed  which  spread  out  and  coalesce.  It  is  cheesy  and  tolerably 
adherent.  It  may  cover  the  surface  of  the  tongue,  the  soft  and  hard 
palate,  the  mucous  membrane  of  the  cheeks ;  it  may  even  extend 
down  into  the  oesophagus ;  occasionally,  we  see  the  whole  surface  of 
the  mouth  and  throat  covered  with  it.  Small  children  have  it  quite 
often ;  adults  only  in  cases  of  severe  illness  when  the  care  of  the 
mouth  is  neglected,  especially  in  fevers,  diabetes,  tuberculosis,  etc. 
Whenever  there  is  a  thick  coating  in  the  mouth  we  must  think  of  this 
growth,  because  its  early  recognition  is  very  important.  The  diagnosis 
is  promptly  made  by  the  aid  of  the  microscope  (see  below). 

For  scars  from  biting  of  the  tongue  during  an  attack  of  epilepsy, 
see  above  under  Wounds.  Dense,  often  depressed,  scars  upon  the 
surface  of  the  tongue  indicate  healed  syphilitic  ulcers. 

When  there  is  a  suspicion  of  syphilis,  the  mucous  membrane  of  the 
mouth  must  be  examined  with  the  greatest  care  (scars,  ulcers  [mucous 
patches]) ;  also,  when  there  is  a  possibility  of  poisoning  with  strong 
mineral  acids  or  alkalies,  corrosive  sublimate,  carbolic  acid  (superficial 
gray  color  and  under  it  marked  injection  of  the  mucous  membrane, 
raw  patches). 

It  may  also  be  the  seat  of  catarrhal  ulcers  as  well  as  of  the  develop- 
ment of  thrush  (see  above).  Cancrum  oris  (Noma)  usually  begins 
with  a  circumscribed  bluish-black  discoloration  of  the  mucous  mem- 
brane of  the  cheek  or  an  ulcer  with  this  condition  around  it  and  with 
a  thick,  inflammatory  infiltration  of  the  cheek.  It  is  a  kind  of 
spontaneous  gangrene  with  a  decivded  reactive  inflammation  in  poor, 
wasting;  children.     It  is  a  rare  disease. 

We  examine  the  floor  of  the  mouth  by  palpation  from  within  and 
without.  It  may  be  the  seat  of  very  dangerous  inflammation  (angina 
Ludwigii). 

Salivary  glands  and  saliva.  Of  the  former  we  notice  only  the 
parotid  gland.  When  it  is  inflamed  there  are  pain  and  swelling,  and 
if  it  proceeds  to  the  formation  of  an  abscess,  there  are  also  redness 
and  fluctuation  above  the  angle  of  the  jaw. 

The  saliva  is  increased  (salivation,  ptyalism)  by  all  kinds  of  irrita- 
tion that  affect  the  mucous  membrane  of  the  mouth :  physiologically 
by  eating,  pathologically  by  all  inflammatory  conditions  of  the  mouth 
(ulcers,  inflammation  of  the  gums  in  connection  with  affections  of  the 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS. 


289 


teeth,  dental  abscess,  etc. ;  corrosive  action  of  acids,  alkalies  in  the 
mouth  and  throat) ;  also,  in  chronic  mercurial  poisoning,  and,  lastly, 
sometimes  in  disease  of  the  medulla  oblongata  (see  Bulbar  Paralysis). 
The  saliva  is  diminished  in  febrile  diseases,  in  diabetes,  in  severe 
diarrhoea  (cholera).  Thus  far  the  chemical  examination  of  the  saliva 
has  been  of  no  diagnostic  value.  It  is  of  interest  that  in  nephritis  it 
may  contain  urea,  and  also  that  thus  far  there  has  never  been  discov- 
ered in  it  any  coloring  matter  from  the  bile  nor  any  sugar.  Many 
substances,  like  iodide  of  potassium,  after  they  have  entered  the 
stomach  appear  remarkably  quickly  in  the  saliva. 

Microscopic  examination  of  the  contents  of  the  mouth.  Normally 
we  find  flat  epithelial  cells  from  the  upper  layer  of  the  mucous  mem- 
brane of  the  mouth,  separate  vrhite  blood-corpuscles,  and  likewise 
micrococci,  bacilli,  and  spirochgeta  (especially  a  microbe  like  the 
cholera  bacillus  and  one  like  the  recurrens  spirilla).  Among  these 
microdrganisms,  no  doubt,  there  are  some  which  may  become  patho- 
genic for  the  individuals  in  whom  they  occur.  In  the  coating  of  the 
teeth  we  find  these  microorganisms  very  abundantly,  and  besides  the 
leptothrix  buccalis  (long  bacilli,  often  forming  long  threads,  which  are 
colored  blue-red  by  iodide  of  potassium,  see  Fig.  82). 


Fig.  82. 


Leptothrix  buccalis,  1000  : 1  (after  Flugge). 


There  is  an  unusually  large  quantity  of  the  different  schizomycetes, 
especially  cocci,  in  any  case  where  the  contents  of  the  mouth  are 
decomposed  (scorbutus,  severe  chronic  mercurial  poisoning,  in  any 
severe  disease  where  there  is  difficulty  in  swallowing,  especially  if  the 
mouth  is  not  carefully  cleaned).  We  also  usually  find  an  abundance  of 
red  and  also  white  blood-corpuscles. 

19 


290  SPECIAL  DIAGNOSIS. 

In  the  common  white  coating  of  the  tongue  there  are  abundant  flat 
epithelial  cells  and  fungi ;  these,  together  with  a  quantity  of  brawn 
detritus,  as  well  as  red  corpuscles,  are  found  in  the  coating  when 
discolored. 

It  is  easy  to  recognize  the  thrush  fungus  under  the  microscope  by 
the  characteristic,  tolerably  broad,  light  fungus-threads  (they  are  more 
than  half  as  broad  as  a  white  blood-corpuscle)  and  by  their  roundish- 
oval,  clear  granules. 

Suppurations  in  the  mouth  proceeding  from  the  inferior  maxilla 
are,  in  rare  cases,  caused  by  actinoinyces.  Whenever  there  is  a  dis- 
charge of  pus  into  the  mouth  we  must  remember  the  characteristic 
granules  (see  p.  175  ;  Microscopic  Examination,  see  p.  189). 

Of  the  soft  palate,  we  are  chiefly  interested  in  the  tonsils.  We  take 
note  of  their  size  and  the  appearance  of  their  surface.  Large  tonsils 
with  deep,  empty  lacunae  indicate  frequent  attacks  of  tonsillitis; 
prominent  white  scars,  syphilis.  If  active  disease  be  present,  we  are 
to  notice  whether  there  are  plugs  in  the  lacunae  (^follicular  tonsillitis) ; 
whether  there  is  a  deposit  upon  the  tonsils,  and,  in  case  there  is, 
whether  it  is  confined  only  to  the  tonsils  and  lacunae  (in  both  cases, 
angina  necrotica) ;  v/hether  it  extends  over  upon  the  arches  (diph- 
theria) ;  Avhether  it  is  loose  or  adherent,  testing  it  with  the  spatula, 
and  whether  we  find  beneath  it  a  necrosis  of  the  tonsil  going  on. 
Dijjhtheria  may  cause  a  deposit  upon  the  arches  of  the  pharynx,  the 
uvula,  all  of  the  soft  palate,  and  even  a  part  of  the  hard  palate.  We 
recognize  an  abscess  of  the  tonsil  by  its  [usually]  being  on  one  side 
only,  with  swelling  of  the  anterior  arch,  by  the  fluctuation  (which  is 
felt  with  the  finger).  Lor  ^--continued  ulcers  of  the  tonsils  and  soft 
palate  are  generally  syphilitic;  more  rarely,  tubercular.  In  the 
latter  case  there  is  often  a  broad,  reticulated,  purulent  discoloration 
of  the  mucous  membrane,  which  reminds  one  of  slightly-inflamed 
pleura  covered  with  a  fine  fibrinous  exudate.  (Paralysis  of  the  Throat, 
see  Nervous  System.) 

In  the  pharynx,  we  look  for  possible  chronic  or  acute  inflammation 
and  ulcers ;   in  children  who,  for  some  unknown  reason,  swallow  badly  - 
and  have    distress  in  breathing,  for  possible  swelling  of  the  posterior 
pharyngeal  wall  (retropharyngeal  abscess,  the   fluctuation  in  which 
may  be  detected  by  palpation). 

We  must  always  examine  the  lymphatic  glands  in  the  neck  in  con- 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  291 

nection  with  the  examination  of  the  throat.  In  all  acute  inflammations 
of  the  latter  they  swell,  most  markedly  in  diphtheria,  also  in  chronic 
inflammations,  especially  syphilis. 

In  diseases  of  the  palate  and  pharynx  the  microscope  gives  very 
little  assistance.  It  is  chiefly  useful  in  tuberculosis.  When  there  is 
a  suspicion  of  a  tubercular  ulcer,  we  scrape  a  little  directly  from  the 
surflice  of  the  ulcer,  but  yet  we  cannot  be  certain  that  we  have  not 
taken  some  tubercular  sputum  which  has  adhered  there.  Long- 
standing plugs  from  lacunae  (often  quite  free  from  irritation)  frequently 
contain  leptothrix  (pharyngomycosis  leptothricia).  The  important 
differential  diagnosis  between  diphtheria  and  benign  necrosis  of  the 
tonsils  cannot,  with  our  present  knowledge,  be  made  by  the  aid  of  the 
microscope. 

Pharyngomycosis  leptothricia  (algosis  faucium  leptothricia)  may,  as 
has  been  observed  in  individual  cases,  extend  from  the  tonsils,  par- 
ticularly to  the  follicular  glands  at  the  root  of  the  tongue,  or  even 
still  further  into  the  trachea  itself.  They  manifest  themselves  as  a 
number  of  distinct,  elevated,  yellowish-white  specks.  The  nature  of 
these  deposits  is  easily  recognized  under  the  microscope,  especially 
after  the  addition  of  iodine  (see  preceding  page). 

Examination  of  the  (Esophagus. 

Preliminary  anatomical  remarks :  The  oesophagus  begins  at  the 
level  of  the  cricoid  cartilage  of  the  larynx  (=  the  lower  border  of  the 
sixth  cervical  vertebra),  and  extends  to  the  stomach,  at  about  the 
height  of  the  base  of  the  xiphoid  process.  At  first  it  lies  immediately 
in  front  of  the  vertebrae,  then  it  comes  a  little  forward,  and,  at  about 
the  seventh  dorsal  vertebra,  it  bends  a  little  to  the  right,  then  again  to 
the  left,  to  reach  the  oesophageal  opening  in  the  diaphragm.  In 
adults,  the  oesophagus  is  about  twenty-five  cm.  long.  When  we 
employ  an  oesophageal  sound,  we  estimate  the  distance  from  the  incisor 
teeth  to  the  stomach  at  about  seventeen  cm.,  in  the  newly  born,  while 
with  adults  it  is  about  forty  cm.  In  the  latter,  the  distance  from  the 
incisor  teeth  to  the  bifurcation  of  the  trachea  is  about  twenty-two  cm. 
The  oesophagus  does  not  have  the  same  diameter  throughout:  its 
narrowest  points  are  at  the  commencement,  and  the  point  where  it 
perforates  the  diaphragm.     The  neighboring  organs  with  which  it  has 


292  SPECIAL  DIAGNOSIS. 

important  relations  in  different  diseases  are :  the  trachea  for  the  upper 
seven  to  eight  cm.  of  the  oesophagus,  the  bronchial  glands,  the  pleura, 
the  pericardium,  the  aorta  from  the  bifurcation  of  the  trachea  down- 
ward, lastly,  the  recurrent  nerve  from  the  bifurcation  upward.  It  is 
only  in  the  neck  that  the  oesophagus  can  be  felt  from  without.  Below 
the  neck,  we  cannot  employ  the  usual  methods  of  examination. 

Characteristic  difficulties  almost  always  occur  with  certain  diseases 
of  this  organ,  namely,  with  those  conditions  which  result  in  stenosis 
(stricture) :  there  are  more  or  less  deeply-seated  difficulties  in  swal- 
lowing ;  the  patient,  after  taking  food,  has  a  feeling  of  pressure, 
or  even  of  pain,  in  the  neck  or  the  chest — a  feeling  that  what  has 
been  taken  cannot  be  passed  down.  According  to  the  place  or  degree 
of  the  stenosis,  the  patient  experiences  difficulty  only  after  taking 
large,  slightly  comminuted  bites  of  food,  or  even  after  swallowing  soup 
or  fluids,  either  immediately  after  the  former  or  only  after  many  bites 
or  swallows.  Moreover,  the  food  may  be  regurgitated,  wholly  or  in 
part,  some  time  after  it  has  been  taken.  Then  we  distinguish  it  from 
vomiting  by  the  absence  of  odor,  of  acid  reaction,  and  of  muriatic 
acid.  Pain  in  swallowing,  without  stenosis,  occurs  with  inflammation 
of  the  mucous  membrane  of  the  oesophagus  or  in  its  near  neighbor- 
hood (mediastinum). 

Examination  of  the  oesophagus  is  almost  confined  to  direct  palpa- 
tion from  within  by  means  of  the  sound,  excepting  that,  in  the  cervical 
portion,  we  can  employ  inspection  and  palpation  from  without. 
Auscultation  furnishes  little,  percussion  no,  aid.  But  it  is  very 
important  in  many  cases  to  examine  the  neighborhood,  particularly 
the  thorax. 

Only  in  exceptional  cases  do  inspection  and  palpation  of  the  cervical 
portion  yield  any  result,  because  the  great  majority  of  diseases  of  the 
oesophagus  are  located  quite  below  the  bifurcation  of  the  trachea.  We 
can  feel  a  carcmomf  ^  the  cervical  portion  (likewise  swelling  of  the 
glands  of  the  neck; ,  we  can  feel,  and  often  also  see,  pulsating 
diverticula  when  they  are  full — that  is,  after  the  patient  has  eaten. 
Carcinoma  of  the  lower  end  of  the  oesophagus  can  be  felt  from  the 
abdomen,  if  the  cardiac  end  of  the  stomach  is  encroached  upon.  Pain 
from  pressure  in  the  neck  occurs  in  the  conditions  above  named  and 
in  inflammations,  as  after  swallowing  acids  and  alkalies. 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  2'93 

Direct  Palpation;  Examination  with  the  Sound. — For 
diagnostic  sounding  of  the  oesophagus  we  employ  either  a  whalebone 
or  English  oesophageal  sound.  The  former  consists  of  a  thin  staff 
with  an  olive-shaped  ivory  knob  screwed  upon  one  end.  We  have 
knobs  of  different  sizes,  in  order  to  determine  and  measure  the  decfree 
of  the  stenosis  (see  below).  Before  using,  we  are  to  make  certain  that 
the  bulb  is  secure  upon  the  staff,  and  also  that  the  staff  is  perfectly 
smooth,  so  as  not  to  catch  anywhere  and  thus  mislead  us.  This  sound 
furnishes  the  most  positive  information,  and  yet  it  requires  the  greatest 
dexterity  and  caution  in  using  it.  The  English  oesophageal  sound  is 
a  cylindrical  India-rubber  tube,  tolerably  stiff  when  cold,  with  its  end 
slightly  smaller  and  closed,  but  having  two  openings  at  the  side. 
Before  using,  it  must  be  somewhat  softened  by  dipping  it  in  warm 
water.  We  must  have  at  hand  several  such  sounds  of  different  sizes. 
The  end  should  always  be  rounded  and  perfectly  smooth,  so  as  not  to 
produce  a  rupture. 

Before  introducing  it,  we  are  to  moisten  only  the  knob  of  the 
whalebone  sound,  but  the  Avhole  of  the  English  sound  with  glycerin 
or  white-  of-egg  (not  with  olive  oil,  nor  with  water).  The  patient  sits 
upon  a  chair  or  the  edge  of  the  bed  with  the  chin  somewhat  elevated. 
The  index  and  middle  fingers  of  the  left  hand  are  introduced  into  the 
mouth,  and  with  them  we  slowly  feel  as  far  as  the  root  of  the  tongue. 
Then  we  seize  the  sound  with  the  right  hand,  like  a  pen-holder,  and 
slowly  push  it  along  the  tongue  under  the  two  fingers.  As  soon  as  it 
passes  beyond  the  ends  of  the  fingers,  we  press  its  end  somewhat 
downward  with  the  tip  of  the  fingers,  and  at  the  same  time  elevate 
the  right  hand,  so  that  the  sound  may  not  strike  against  the  back  of 
the  throat.  The  sound  is  then  with  gentle  pressure  pushed  on, 
always  holding  it  as  if  writing.     The  left  hand  is  now  withdrawn. 

Special  precautionary  measures,  such  as  placing  a  cork  between  the 
teeth,  or  anything  to  hold  the  jaw,  are  usually  not  necessary,  since  this 
operation  is  not  performed  upon  unwilling  or  unconscious  patients 
(see  Sounding  the  Stomach).  Only  with  children  are  we  sometimes 
obliged  to  use  the  cork.  Many  patients  bear  a  skilfully-performed 
sounding  very  well,  but  others  can  only  become  accustomed  to  it 
from  considerinsr  its  beneficial  results.  If  the  motions  of  strang-lino- 
are  not  severe,  we  need  not  be  disturbed  by  them,  but  if  there  is 
vomiting  we  must  at  once  withdraw  the  sound  in  order  that  there  may 


294  SPECIAL  DIAGNOSIS. 

be  no  choking.  A  slight  spasm  of  the  glottis  and  momentary 
arrest  of  breathing  have  no  significance,  yet  attention  is  called  to  the 
second  paragraph  below. 

We  sometimes  meet  with  a  resistance  which  is  not  pathological : 
1.  At  the  posterior  wall  of  the  throat,  but  only  with  unskilful  intro- 
duction of  the  sound  (see  above).  2.  Sometimes,  if  the  cricoid  cartilage 
of  the  larynx  overlaps  the  oesophagus  somewhat,  from  the  point  of  the 
sound  striking  against  it ;  this  is  easily  passed  by  withdrawing  it  a 
little,  and  then  pushing  it  on  again.  3.  By  spasm  of  the  oesophagus, 
caused  by  the  sound,  which  disappears  soon  by  waiting. 

Two  occurrences  may  endanger  the  life  of  a  patient :  1.  The  intro- 
duction of  the  sound  into  the  trachea,  which  very  rarely  happens.  At 
any  rate,  as  soon  as  there  is  marked  diflSculty  in  breathing  the  sound 
is  to  be  withdrawn.  If  the  patient  is  able  to  pronounce  "a"  clearly, 
moreover,  if  the  portion  of  the  sound  introduced  is  longer  than  the 
trachea,  then  we  know  that  it  has  not  entered  the  trachea.  Other 
signs  are  deceptive.  2.  A  still  greater  danger  is  that  the  wall  of  the 
oesophagus  may  be  injured  or  ruptured.  This  results  from  narrowing 
of  the  canal,  if  it  has  become  thin  and  fragile  from  a  crumbling  new 
formation,  or  by  an  ulceration,  or  when  an  abscess  or  aneurism  near 
the  oesophagus  is  thus  perforated.  The  results  of  these  are  either 
ichorous  mediastinus  or  pleurisy  with  fatal  termination,  or  if  an  aneu- 
rism, with  immediately  fatal  hemorrhage.  We  must  never  employ 
force  if  the  sound  meets  with  resistance.  If  we  can  confirm  the 
suspicion  of  an  aneurism  by  examining  the  chest,  we  are  always  to 
omit  using  the  sound. 

Examination  with  the  sound  gives  information  in  the  following  ways : 

1.  Sometimes  a  deep-seated  pain  occurs  after  the  examination  has 
been  made  several  times,  although  the  sound  has  only  been  introduced 
a  certain  distance.  It  may  depend  upon  inflammation  in  that  neighbor- 
hood (for  determining  its  height,  see  under  "  Stenosis"),  upon  an  ulcer, 
a  carcinoma  not  causing  stenosis,  a  purulent  oesophagitis,  or  perioeso- 
phagitis. 

2,  The  sound  meets  with  resistance.  Then  the  patient,  in  many 
cases,  is  sensible  of  pressure,  or  has  a  sensation  of  pain ;  sometimes 
there  is  severe  strangulation.  We  move  the  sound  back  and  forth,  and 
endeavor  to  advance  it  with  very  slight  pressure.  We  mount  a  smaller 
knob  upon  the  whalebone  sound,  or  take  a  thinner  rubber  one.     But 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS. 


295 


the  smaller  the  sound  the  greater  the  danger,  and  hence  greater  caution 
is  required  in  using  it. 

If  we  are  at  length  able  to  advance  it  further,  then  we  feel  resist- 
ance just  so  long  as  the  knob  is  in  the  stenosed  portion.  After  passing 
the  narrowed  part,  it  again  passes  easily,  but,  of  course,  meets  with 
resistance  at  the  same  point  as  it  is  withdrawn. 

We  obtain  information  regarding  the  situation  of  a  stricture,  by- 
bearing  in  mind  the  rules  given  when  referring  to  the  anatomy  of  the 
parts.  We  introduce  the  sound  as  far  as  the  stenosis,  note  the  loca- 
tion, starting  from  the  incisor  teeth  (by  seizing  the  sound  accurately 
Avith  the  fingers),  draw  it  out  and  measure  it. 

Regarding  the  degree  and  length  of  the  stenosis :  we  learn  the  former 
by  the  thickness  of  the  sound  that  will  just  pass  the  stricture:  the 
length  of  the  stricture  will  best  be  ascertained  by  employing  whale- 
bone sounds,  in  that  we  can  mark  the  place  where  the  incisor  teeth 
touch  the  sound  when  it  enters  the  stenosis,  and  as  it  passes  through 
the  stenosis.  Also,  if  there  is  a  double  stenosis,  it  is  indicated  (see 
Fig.  83). 

We  can  learn  almost  nothing  regarding  the  nature  of  the  stenosis, 
unless  we  should  catch  in  the  fenestrum  of  an  India-rubber  sound  a 
shred  of  tissue  which  would  enable  us  to  diagnose  a  carcinoma,  or 
unless  we  should  meet  Avith  the  condition  described  in  the  next  sec- 
tion (3). 

Fig,  83. 


Diagrammatic  representation  of  sounding  the  cesophagus  whcu  there  id  a  short, 
long,  and  a  double  stenosis. 


3.  By  repeated  introductions  of  the  sound,  we  are  sometimes  able 
to  pass  it  through,  but  if  again  we  meet  with  an  insuperable  obstruc- 
tion we  must  be  very  careful :  this  points  to  a  diverticulum,  though 


296 


SPECIAL  DIAGNOSIS. 


Fig.  84. 


not  indeed  with  absolute  certainty,  since  it  may  be  met  with  in  other 
kinds  of  stenosis, 

4.  In  a  case  of  stenosis  which  we  have  repeatedly  examined,  we 
suddenly  find  ourselves  unable  to  get  the  smallest  sound  through, 
where  it  has  frequently  passed  easily.  This 
may  indicate  an  obstruction  by  a  foreign  body, 
as  was  the  case  in  one  instance  under  my 
observation,  which  ended  fatally,  where  a 
cherry  stone  was  found  in  the  stenosis. 

5.  The  end  of  the  sound  may  meet  with 
opposition  upon  one  side  and  not  upon  the 
other.  This  indicates  a  dilatation  of  the 
oesophagus  (generally  above  the  stenosis). 

Stenosis  may  be  caused  by  scars  resulting 
from  swallowing  a  corrosive  fluid  some  time 
before  (Anamnesis),  or  by  carcinoma  of  the 
oesophagus,  or  by  diverticula  (see  above  under 
3) ;  these  are  generally  high  up  in  the  oesoph- 
agus; or  by  compression  of  the  oesoph- 
agus. Congenital  stenosis  (difiiculty  in 
swallowing  from  birth),  and  stenosis  caused 
by  thrush,  are  both  very  rare. 

Examination  of  the  neighborhood  of  the  oesophagus,  that  is  of  the 
neck  and  thorax,  is  of  the  greatest  importance.  We  are  thus  able  to 
discover  compressing  tumors,  or  to  exclude  them  with  probability. 
We  may  aid  the  diagnosis  by  giving  attention  to  the  larynx,  and 
observing  whether  there  is  a  recurrent  paralysis,  which  may  exist  even 
though  the  voice  be  quite  clear.  Compression  of  the  recurrent  nerve 
sometimes  occurs  in  carcinoma  of  the  oesophagus,  with  aneurism  of  the 
aorta  (particularly  the  left  nerve).  Moreover,  we  take  into  considera- 
tion the  examination  of  the  chest,  especially  whenever  there  is  any 
evidence  of  a  rupture,  as  in  pleuritis,  gangrene  of  the  lungs,  rupture 
into  the  trachea  or  bronchus,  with  coughing  up  of  particles  of  food; 
pericarditis,  and  emphysema  of  the  skin  (see). 

Percussion  of  the  oesophagus  itself  can  be  of  almost  no  aid.  Large 
diverticula  in  the  neck  may  show  dulness,  provided  they  are  full. 
Exceptionally,  a  dilatation  above  a  stenosis  in  the  thoracic  portion  may, 
if  full,  also  produce  dulness. 


a.  Sounding  the  oesopha- 
gus when  the  diverticulum 
is  full;  b.  sounding  when 
the  diverticulum  is  empty. 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  297 

Auscultation  of  the  oesophagus  is  of  very  subordinate  value.  It 
can  be  employed  as  far  as  to  the  seventh  thoracic  vertebra  at  the  left 
of  the  spine,  in  examining  the  lower  part  of  the  oesophagus ;  or  we 
may  listen  over  the  spine  or  to  the  right  of  it.  Ir^  health,  when  fluids 
are  being  swallowed,  we  can  hear  a  gurgling  in  the  whole  extent  of 
the  oesophagus.  When  there  is  stenosis,  we  sometimes  notice  that  the 
gurgling  ceases  just  at  that  point.  The  sounds  of  swallowing  which 
we  hear  at  the  stomach  are  less  certain  signs  than  this  phenomenon ; 
in  health,  there  is  sometimes  heard  a  sound  six  or  seven  seconds  after 
an  act  of  swallowing,  as  of  something  being  pressed  through,  and  some- 
times preceding  this  is  a  sound  of  squirting  (Kronecker  and  Meltzer, 
B.  Frankel). 

(Esophagoscopy  (illuminating  the  oesophagus  with  an  electric  light) 
has  not  yet  attained  a  position  as  a  recognized  method  of  examination. 

Examination  of  the  Stomach. 

Topography  of  the  abdomen.  This  is  represented  in  the  accom- 
panying figure.  We  form  the  different  sections  by  prolonging  the  mam- 
millary  lines  (or  a  line  which  passes  from  the  middle  of  Poupart's 
ligament  upon  each  side) ;  also  by  lines  which,  in  the  upright  position, 
are  drawn  through  the  ends  of  the  eleventh  ribs,  and  through  the 
anterior  superior  spines  of  the  ilei.  By  these  latter  lines,  the  section 
lying  between  the  mammillary  lines  is  divided  into  the  epigastrium, 
mesogastrium,  and  hypogastrium.  It  is  further  to  be  added  that  the 
region,  directly  over  Poupart's  ligament,  which  extends  inward  toward 
the  symphysis  pubis,  and  outward  somewhat  over  the  middle  of  the 
ligament,  is  called  the  inguinal  region,  and  the  territory  below  the 
ends  of  the  ribs,  the  hypochondrium.  So  far  as  the  abdominal 
contents  are  parietal,  their  relations  to  the  separate  regions  of  the 
abdomen  are  plainly  indicated  in  the  accompanying  figure. 

ANATOMY    OF    THE    STOMACH.  ' 

Only  a  little  more  than  the  pyloric  portion  [one-sixth]  of  the 
stomach  lies  in  the  right  half  of  the  body,  the  rest  [five-sixths]  being 
on  the  left  of  the  median  line.  It  slopes  obliquely  from  the  left 
downward  toward  the  right,  so  that  the   cardia  is  about  behind  the 


298 


SPECIAL  DIAGNOSIS. 


Sternal  insertion  of  the  seventh  rib,  the  pylorus  between  the  right 
sternal  and  parasternal  lines,  on  a  level  with  the  apex  of  the  xiphoid 
cartilage.  The  fundus — the  portion  situated  the  highest,  clinging  to 
the  left  side  of  the  dome  of  the  diaphragm — rises  as  high  as  the  fourth 


Fig.  85. 


Might  mammillary  line.' 


CJir 


E.J'1 


,Left  mammillary  line. 


-EJla. 


-CD. 


Position  of  the  abdominal  contents. 
(M.  Ascending  colon.     CD.  Descending  colon.    iiJ"- C.  Ileocecal  region.    i?J".  Inguinal 
region.     RHs.  Left  hypochondriam.     EE.  Epigastrium.     RU.  Umbilical  region.     H. 
Hypogastrium. 

intercostal  space.  The  lesser  curvature  forms  a  bow  with  its  con- 
vexity arranged  obliquely  downward  toward  the  left.  It,  with  the 
cardia  and  pylorus,  which  it  connects,  lies  more  posteriorly,  covered 
by  the  liver,  while  the  greater  curvature  extends  forward  toward  the 
abdominal  wall ;    so  that  a  line  drawn  from  the  lowest  point  of  the 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  299 

lesser,  to  the  lowest  point  of  the  greater,  curvature  would  incline 
forward  and  downward.  The  situation  of  the  greater  curvature  varies 
very  much  with  the  degree  of  distention  of  the  stomach.  In  health, 
it  only  very  exceptionally  extends  to  the  umbilicus. 

The  fundus  of  the  stomach  is  adjacent  to  the  diaphragm,  the  spleen, 
and  the  left  kidney  ;  its  greater  curvature,  and  also  the  lower  part  of 
its  posterior  surface,  to  the  transverse  colon ;  the  pylorus,  lesser 
curvature,  and  that  portion  of  its  anterior  surface  which  is  near  to 
these,  to  the  left  lobe  of  the  liver.  Behind  and  above  the  stomach, 
situated  at  the  upper  part  of  its  posterior  surface,  is  the  sinus  of  the 
peritoneal  cavity,  the  bursa  omentalis  (pathologically  not  unimportant), 
and  also  the  pancreas. 

When  the  stomach  is  moderately  distended,  a  part  of  the  anterior 
surface,  and  the  greater  curvature,  are  parietal,  so  far  as  they  are  not 
prevented  by  the  lung  or  heart  from  above,  or  by  the  spleen  on  the 
left,  and  by  the  left  lobe  of  the  liver  on  the  right.  That  part  of  the 
parietal  surface  of  the  stomach  which  is  covered  by  the  left  lower 
portion  of  the  ribs  comprises  the  important  region  to  which  Traube 
gave  the  name  of  "  halfmoon-shaped  space."  We  see  from  this 
description  that,  with  moderate  distention,  only  a  small  part  of  the 
healthy  stomach  can  be  directly  examined.  The  most  important 
parts,  the  cardia  and  pylorus,  are  bent  deeply  in.  But  we  have  a 
favorable  moment  for  examining  the  latter  in  certain  pathological 
conditions,  where  it  is  desirable  to  be  able  to  judge  of  it,  it  being  often 
pushed  down  with  the  lesser  curvature  below  the  liver. 

INSPECTION    AND    PALPATION    OF    THE    STOMACH. 

There  is  scarcely  any  place  where  inspection  and  palpation  are  so 
closely  connected  as  at  the  abdomen,  and  especially  the  stomach.  The 
patient  is  placed  so  as  to  lie  comfortably,  with  the  upper  portion  of 
the  body  moderately  raised.  We  look  at  the  region  of  the  stomach 
with  the  greatest  care,  illuminating  it  from  all  possible  directions ; 
then  palpate  with  the  tips  of  the  first,  second,  and  third  fingers, 
and  thus  notice  first  the  tenderness  (always  at  first  proceeding  very 
cautiously),  then  the  objective  condition,  finally  completing  the  palpa- 
tion with  inspection,  or  vice  versa. 

The  result  of  the  two  methods  of  examination  will  be  affected  by 


300  SPECIAL  DIAGNOSIS. 

several  factors — by  the  size,  sharpness  of  the  boundaries,  and  density 
(resistance)  which  we  discover  in  the  abdominal  wall,  and  its  condition. 
As  regards  the  latter,  it  is  important  for  the  examiner  to  avoid 
causing  contraction  of  the  abdominal  muscles,  by  having  the  patient 
in  the  recumbent  posture,  cautioning  him  to  keep  the  muscles  lax, 
and  by  proceeding  slowly  with  the  palpation,  the  hands  being  warmed. 
Contraction  of  the  recti  abdominis,  with  their  short  tumor-like  sec- 
tions of  muscle,  may  very  much  disturb,  or  even  deceive,  one  in 
making  an  examination.  As  to  the  general  thickness  of  the  abdominal 
walls  in  chronic  diseases  of  the  stomach,  especially  if  very  severe,  this 
is  very  much  lessened  by  wasting — a  condition  favorable  for  making 
an  examination. 

The  normal  stomach  cannot  at  all  distinctly  be  recognized  or 
defined  through  the  abdominal  wall.  It  can  only  exceptionally  be 
done  when  there  is  extreme  emaciation. 

I  remember  two  cases  where,  in  extremely  wasted  females  Avith 
very  lax  walls,  the  greater  curvature  and  peristalsis  of  the  anterior 
wall  of  the  stomach  could  be  clearly  seen.  In  both  cases  the  stomach 
was  very  slightly  distended,  and  in  both  cases  the  autopsy  showed  a 
normal  condition  of  the  stomach. 

On  the  other  hand,  the  healthy  stomach,  distended  with  food  or 
gas,  sometimes  enables  us  to  imagine  its  condition  by  the  projection 
in  the  epigastrium,  and  still  more  by  a  high  halfmoon-shaped  space — 
that  is,  by  tympanitic  resonance  over  the  left  lower  lobe  of  the  lung 
in  the  side  (see  under  Percussion).  We  can  sharply  bound  a  healthy 
stomach  only  in  individual  cases  when  it  is  inflated  with  gas  (see 
method  of  procedure,  p.  301).  Thus,  it  has  been  found  that  the 
greater  curvature  of  a  normal  stomach,  when  very  greatly  distended, 
may  reach  as  far  as  the  umbilicus.  Of  course,  we  cannot  ascertain 
the  location  of  the  lesser  curvature.  Moreover,  the  distensibility  of 
the  healthy  stomach  varies  very  much  with  different  persons,  so  that 
on  trial  one  person  earlier,  and  another  later,  has  difficulty,  especially 
oppression,  which  marks  the  limit  of  distention. 

The  chief  pathological  signs  furnished  by  the  stomach  are,  its  dis- 
tention or  displacement,  its  thickness,  and  amount  of  peristaltic  action 
of  its  walls,  also  signs  of  circumscribed  tumors  in  its  walls.  Other 
important  signs  are  to  be  added  to  those  already  mentioned.  Pain 
upon  pressure  during  palpation  requires  a  special  description. 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS,  301 

Distention  is  more  or  less  distinctly  made  out  bj  inspection  and 
palpation,  according  to  its  extent  and  the  thinness  of  the  abdominal 
walls.  But  it  may  also  entirely  elude  examination.  In  favorable 
cases,  we  can  see  and  feel  (easily  when  looking  down  from  the  patient's 
head)  the  greater  curvature.  To  a  varying  extent  it  moves  down, 
often  below  the  umbilicus,  more  rarely  nearly  to  the  symphysis,  and 
in  so  doing  it  shows  the  bend  toward  the  left.  The  position  of  the 
greater  curvature,  of  course,  varies  with  the  degree  of  fulness  of  the 
stomach,  but  usually,  unless  artificially  emptied,  as  by  emesis  or  the 
stomach-pump,  it  does  not  come  up  above  the  umbilicus.  Thus,  the 
pyloric  portion  behaves  peculiarly,  in  that  it  influences  the  situation 
of  the  stomach  and  renders  the  pylorus,  as  well  as  the  lesser  curva- 
ture accessible  for  examination.  When  the  stomach  is,  for  the  time 
being,  distended  by  a  large  quantity  of  food,  in  the  upright  position 
of  the  patient,  it  pulls  the  pylorus  forward  from  under  the  liver,  and 
with  it,  under  some  circumstances,  the  lesser  curvature.  This,  in 
rare  cases,  is  seen  in  the  upper  epigastrium,  in  a  line  convex  down- 
ward (when  the  light  falls  from  the  foot  of  the  bed),  when  it  may  even 
be  felt.  Also  the  portio  pylorica,  and  the  pylorus  itself,  may  be  felt 
(see  under  Tumors).  In  consequence  of  this  displacement  of  the 
pylorus,  the  whole  stomach  slopes  more  strongly  downward  toward 
the  right. 

In  rare  cases,  the  pylorus  stands  as  low  down,  without  there  being 
any  dilatation  of  the  stomach.  The  condition  is  congenital,  or  caused 
by  strong  adhesions  (Kussmaul). 

As  has  already  been  mentioned,  the  distinctness  with  which  the 
figure  of  the  stomach  can  be  made  out  is  largely  influenced  by  the 
extent  of  its  fulness.  Hence,  for  the  purpose  of  making  the  examina- 
tion, we  must  artificially  distend  it  (Frerichs).  Until  very  recently, 
this  was  always  done  with  carbonic  acid,  by  giving  the  patient  as 
much  as  two  teaspoonfuls  of  tartaric  acid  and  bicarbonate  of  soda  dis- 
solved in  a  little  water.  The  gas  quickly  develops  in  the  stomach, 
and  demonstrates  clearly  the  situation  and  size  of  the  organ,  rendering 
the  examination  of  its  walls  easy  (see  under  Peristalsis  and  Hyper- 
trophy). But  this  procedure  sometimes  gives  rise  to  a  feeling  of 
oppression,  and  even  of  symptoms  of  collapse ;  and  recently  there  has 
been  devised  a  method  of  inflating  the  stomach  which  is  much  more 
to  be  recommended,  because  the  amount  of  gas  for  distending  the 


302  SPECIAL  DIAGNOSIS. 

stomach  can  be  regulated  exactly,  and,  if  necessary,  it  can  be  emptied 
out  in  an  instant.  A  Nelaton  stomach-sound  is  introduced  (just  as  in 
sounding  the  oesophagus),  and  then  the  stomach  is  inflated  with  air 
through  the  sound  by  means  of  an  India-rubber  ball,  introducing  as 
much  as  is  necessary,  or  as  the  patient  can  bear.  At  any  time  the 
air  can  immediately  be  let  out  through  the  sound. 

By  inflating  the  stomach,  Eichhorst  has  several  times  easily  recog- 
nized the  so-called  hour-glass  stomach  (twice  it  was  formed  by  a  scar 
which  strictured  it  in  the  middle).  In  the  same  way,  we  can  discover 
that  the  pylorus  does  not  close,  by  the  fact  that  the  gas  blown  in  does 
not  distend  the  stomach,  but  immediately  enters  the  small  intestine. 

Ziemssen  still  gives  the  preference  to  distention  with  carbonic  acid. 
In  his  last  communication  he  gives  the  proportions  for  adult  men  as 
seven  grammes  of  bicarbonate  of  soda  and  six  grammes  of  tartaric 
acid,  for  adult  women,  one  gramme  less  of  each. 

The  sound  may  be  employed  in  the  same  way  as  with  the  oesophagus 
to  determine  stenosis  at  the  eardia,  due  to  cancer.  (The  employment 
of  an  English  oesophageal  sound  for  ascertaining  the  size  of  the 
stomach  [Leube]  requires  the  greatest  caution.  The  sound  is  intro- 
duced into  the  stomach  and  pushed  on  until  it  meets  resistance  at  the 
greater  curvature,  and  then  we  ascertain  where  the  end  of  the  sound 
is  by  palpation  from  without.) 

Regarding  palpation  by  striking  and  the  resulting  splashing,  see 
under  Auscultation.  In  the  neighborhood  of  the  stomach  we  may 
have  epigastric  pulsation  (see  p.  204),  liver-pulse  (see  p.  266),  lastly 
it  may  be  communicated  from  the  aorta  or  from  aneurism  of  the 
abdominal  aorta.  With  tumors  of  the  stomach,  the  pulsation  from  the 
aorta  is  usually  very  distinctly  transmitted. 

Increased  resistance;  peristaltic  motions.  The  former  occurs 
simultaneously  with  the  general  distention  of  the  stomach  in  conse- 
quence of  the  hypertrophy  of  the  muscular  portion,  which  generally 
accompanies  dilatation  of  the  stomach.  Hence,  it  is  an  indirect  sign 
of  dilatation. 

If  it  is  found  within  a  limited  area,  as  in  the  right  half  of  the  epi- 
gastrium, even  if  it  is  not  sharply  defined,  it  may  indicate  carcinoma. 
We  must  be  careful  not  to  confound  it  with  contraction  of  one  of  the 
bellies  of  the  rectus  abdominis.  Peristaltic  motions  which  can  be 
felt  as  well  as  seen  are  very  important,  being  often  the  first  signs  of 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  303 

a  hypertrophy,  and,  thus,  a  dilatation.  By  their  situation  and  extgit, 
they  may  also  indicate  the  size  of  the  stomach.  It  is  very  rare  for 
them  to  occur  without  dilatation — in  nervous  "  peristaltic  unrest  "  of 
the  stomach  (Kussmaul).  Generally  it  extends  in  the  normal  direc- 
tion from  the  fundus  to  the  pyloric  region.  But  sometimes  it  is 
reversed  (marked  pyloric  stenosis,  Kussmaul) — antiperistalsis.  It  will 
often  be  excited  or  increased  by  gentle  strokes,  and  by  faradization ; 
sometimes  by  irritation, of  the  skin,  as  by  simply  uncovering  it.  With 
very  lean  persons,  we  must  think  of  the  possibility  of  it  being,  under 
some  conditions,  intestinal  peristalsis. 

Tumors  in  the  region  of  the  stomach  are  often  only  to  be  felt, 
not  seen.  They  cannot  be  demonstrated  if  connected  with  a 
part  of  the  stomach  that  is  not  parietal :  cardia,  lesser  curvature, 
posterior  wall  of  the  stomach,  commencing  cancer  of  the  pylorus. 
These  tumors  are  most  frequently  cancer  of  the  stomach  (more  rarely 
a  dense  scar  from  ulcer),  and  are  most  often  located  to  the  right  of 
the  middle  line,  because  they  belong  to  the  portio  pylorica  or  to  the 
pylorus  itself.  In  the  latter  case,  they  can  generally  only  be  felt 
when  the  pylorus  is  pushed  downward,  as  has  already  been  mentioned. 
Carcinoma  usually  feels  uneven  and  dense.  Less  frequently  it  is 
smooth,  and  can  then  easily  be  overlooked,  or  be  mistaken  for  a  belly 
of  the  rectus  (see  above,  under  Resistance).  Projection  of  the  stomach 
during  deep  breathing,  as  a  result  of  the  movements  of  the  diaphragm, 
usually  does  not  take  place  at  all,  for  the  reason  that  the  stomach  is 
not  a  solid  body.  We  observe  a  slight,  or  possibly  a  marked,  respira- 
tory displacement  when  there  is  adhesion  of  the  distended  pylorus  and 
the  liver  (see),  or  if  there  is  a  tumor  which  extends  from  the  sub- 
phrenic region  to  a  parietal  portion  of  the  stomach.  Dense  scars 
from  ulcers  and  the  infrequent  hypertrophy  of  the  pylorus,  also  solid 
bodies  that  have  been  swallowed,  may  feel  like  tumors.  Mistaking 
them  for  scybala  in  the  transverse  colon  (see  Intestine)  is  not  likely 
to  happen. 

In  all  diseases  of  the  stomach,  pain  upon  pressure  during  palpation 
may  be  wanting.  It  is  absent  least  frequently  with  ulcer  of  the 
stomach.  If  there  is  pain,  it  may  vary  very  much  :  in  acute  catarrh 
of  the  stomach,  also  som-etimes  in  chronic,  it  is  dull  and  quite  diiFuse ; 
with  ulcer,  it  is  often  very  much  circumscribed,  limited  to  a  spot  the 
size  of  a  dime,  extremely  severe,  often  shooting  through  to  the  back 


304 


SPECIAL  DIAGNOSIS. 


(especially  toward  the  left) ;  in  carcinoma,  there  is  sometimes  a  marked 
insensibility,  sometimes  a  more  diffuse,  sometimes  a  narrowly-defined, 
pain  of  various  intensity. 


PERCUSSION    OF    THE    STOMACH. 


This  applies  to  that  portion  of  the  anterior  wall  of  the  stomach 
which  lies  against  the  abdomen  and  the  anterior  (left  lower)  wall  of 
the  thorax.  It  yields,  in  much  the  greater  majority  of  cases,  a  very 
deep  tympanitic  sound ;  and  sometimes,  when  there  is  marked  tension 


Fig. 


Percussion  boundary  of  the  lungs  in  front.  (Weil.)  ff,h.  the  upper  boundary  of  the 
lungs;  e,f,  the  lower  boundary  of  the  lungs;  6, c?,  boundary  between  the  lung  and 
heart  at  the  incisura  cardiaca.  The  dark  hatched  surface  represents  the  portions  of  the 
heart  and  liver  that  are  in  contact  with  the  chest-wall;  the  light  hatching,  the  so-called 
relative  heart-  and  liver  deadness  (see  later),  m,  spleen-deadness ;  n,  the  average 
position  of  the  lower  boundary  of  the  stomach. 


of  the  stomach,  a  clear  non-tympanitic  sound.  If  the  stomach  con- 
tains a  considerable  amount  of  food  it  may,  in  part  (especially  in 
standing),  have  an  absolutely  dull  sound.  But  we  hardly  ever  find  it 
dull  throughout  the  whole  extent  of  that  portion  of  the  stomach  that 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  305 

is  parietal,  because  it  almost  always  contains  considerable  gas  as  well 
as  food.  The  tympanitic,  as  well  as  the  non-tympanitic,  stomach- 
sound  frequently  has  a  metallic  quality. 

The  boundaries  of  the  stomach  are  determined  by  topographical 
percussion  (see  Fig.  86). 

On  the  side  toward  the  liver,  there  is  a  dull  sound;  it  is  often 
difficult  to  make  out,  because  the  border  of  the  liver  is  thin  (see  Per- 
cussion of  the  Liver).  On  the  side  toward  the  lung,  theie  is  a  non- 
tympanitic,  clear  sound.  Here  it  is  often  difficult  to  mark  sharply  the 
boundary  line,  on  account  of  the  thinness  of  the  border  of  the  lung  and 
the  similarity  of  the  two  sounds. 

Sometimes  we  have  to  distinguish  a  boundary  of  the  stomach  from 
the  heart,  should  its  apex  reach  further  toward  the  left  than  the 
liver;  sometimes  from  the  spleen,  if  the  stomach  should  be  stretched 
out  somewhat.  We  can  separate  it  from  the  large  and  small  intes- 
tine, both  of  which  give  a  tympanitic  sound. 

Except  these  last  named,  the  boundary  lines  are  all  dependent 
upon  the  situation  and  size  of  the  surrounding  organs.  Therefore, 
and  because  there  are  no  true  boundary  lines  for  the  stomach,  except 
its  parietal  boundaries,  we  do  not  employ  percussion  for  the  stomach. 
The  only  real  boundary  is  that  on  the  side  toward  the  intestine,  which 
gives  the  situation  of  the  greater  curvature. 

But  it  is  almost  always  very  difficult  to  determine  this  line  (there 
being  a  tympanitic  sound  on  both  sides  of  it,  with  only  a  difference  in 
pitch).  We  can  hardly  even  maintain  its  correctness  without  the  aid 
of  inspection  and  palpation.  Thus,  percussion  of  the  stomach,  for  the 
great  majority  of  cases,  has  an  extremely  doubtful  value. 

On  the  whole,  we  get  the  best  results  from  percussion  in  health,  and 
particularly  when  the  stomach  has  been  artificially  dilated.  With  the 
former,  we  then  find  that  the  greater  curvature  usually  is  somewhat  above 
the  umbilicus,  sometimes  reaching  to  it.  When  the  stomach  is  moder- 
ately full,  it  commonly  stands  about  midway  between  the  apex  of  the 
xiphoid  process  and  the  umbilicus.  If  the  stomach  is  dilated,  the 
boundary  is  lower  down  (see  Inspection,  Palpation).  Likewise,  should 
the  lesser  curvature  be  lower  down,  it  can  be  made  out  by  the  aid  of 
percussion. 

.     Another  procedure,  but  one  which  is  not  always  successful,  is  first 
to  empty  the  stomach  as  much  as  possible  (see  Emesis),  then  to  percuss 

20 


306  SPECIAL  DIAGNOSIS. 

the  abdomen,  the  patient  being  in  the  standing  position.  Usually  we 
do  not  find  any  boundary  for  the  stomach.  Then  we  have  the  patient 
drink  freely,  and  again  percuss  while  he  is  standing.  In  the  lower 
part  of  the  stomach,  hence  above  the  greater  curvature,  about  in  the 
middle  line,  we  shall  find  a  dulness  which  indicates  the  situation  of  the 
greater  curvature,  and  thus  a  possible  dilatation  may  be  recognized 
(modified  after  Penzoldt).  This  dulness  may  sometimes  be  directly 
proved,  without  any  preliminary  procedure,  if  the  stomach  is  partly 
filled  with  fluid.     The  dulness  disappears  when  the  patient  lies  down. 

There  is  distinct  dulness  with  tumors  of  the  stomach  (strong  per- 
cussion) only  when  they  are  very  thick,  and  this  is  not  often  the  case. 
Hence  they  usually  give  stomach-resonance.  But  tumors  of  the  liver 
and  spleen,  on  the  other  hand,  almost  always  are  dull  because  they  are 
larger.     Yet  this  diiference  is  not  an  entirely  sure  sign. 

Rod-2Jleximeter-2yercuss{on  (see  p.  136)  over  the  stomach  usually 
gives  a  beautiful  silver  tone.'  It  is  employed  for  determining  the 
boundary,  under  the  supposition  that  in  this  way  the  person  who  is 
listening  over  the  stomach  must  hear  the  high  silver  tone  just  so  long 
as  his  assistant  percusses  over  the  stomach  ;  but  the  result  of  this  pro- 
cedure is  hardly  ever  positive  enough  to  give  it  value. 

That  part  of  the  left  lower  lobe  of  the  lung  is  designated  as  the 
"circular  stomach-lung  space,"  where  a  tympanitic  sound  may  be 
heard  with  strong  percussion  (Ferber).  We  may  likewise  speak  of  a 
'^  circular  stomach-liver  space,"  sometimes  even  of  a  "stomach-heart 
space  "  (see  page  206).  None  of  these  have  any  value  for  determining 
the  size  of  the  stomach. 

The  Half-moon-shaped  Space  (Traubb\ — It  is  that  portion  of 
the  lower  left  part  of  the  thorax  which  lies  below  the  lung  (or  heart) 
between  the  liver  and  spleen,  and,  as  a  rule,  in  health  gives  a  tympa- 
nitic sound,  most  frequently  a  stomach  sound,  but  not  infrequently 
also  an  intestinal  sound,  or  both.  It  is  discovered  by  gentle  per- 
cussion. Occasionally,  in  health,  we  here  find  dulness  instead  of 
tympanites',  and  then  only  when  the  stomach  is  decidedly  full,  or  when 
the  full  transverse  colon  is  here  parietal,  or  when  the  greater  omentum 
is  unusually  loaded  with  fat  (Weil). 

In  enlargemeyit  of  the  liver.,  of  the  left  heart,  and  of  the  spleen, 
this  space  will  always  be  found  correspondingly  smaller.  But  its 
behavior  in  certain  conditions  of  the  left  lung,  or  of  the  left  pleura,  is 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  307 

of  especial  diagnostic  interest.  Exudation  in  the  left  pleura  usually 
causes  dulness  correspondingly  early  in  the  upper  portion  of  this  space, 
in  that  it  first  collects  in  the  complementary  pleural  sinus.  As  the 
exudation  increases,  the  half  moon-shaped  space  diminishes  more 
and  more,  the  dulness  sometimes  extending  as  far  as  the  bend  of 
the  ribs,  depending  upon  the  amount  of  downward  pressure  of  the 
diaphragm  (unless  there  are  pleuritic  adhesions  in  the  pleural  sinus,  in 
which  case  we  do  not  have  the  space  diminished).  As  the  pleuritic 
exudation  is  absorbed,  the  space  resumes  its  normal  proportions,  and 
if  there  is  shrinking  after  the  absorption,  it  becomes  greater  than 
normal,  for  the  reason  that  the  lower  border  of  the  lungs  does  not 
again  come  down  to  its  former  place,  and,  on  the  other  hand,  the 
diaphragm  stands  higher.  Rarely,  -with  pneumonia  of  the  whole  left 
lung,  or  its  lower  lobe,  the  half-moon-shaped  space  becomes  very  slightly 
smaller,  as  a  result  of  the  enlargement  of  the  lung  during  hepatization, 
and  also,  probably,  from  a  small  pleuritic  exudation. 

It  is  to  be  observed  that  in  an  acute  disease  of  the  left  half  of  the 
chest,  an  early  distinct  diminution  of  the  half- moon- shaped  space  is 
made  manifest  by  a  certain  degree  of  dulness ;  a  marked  diminution  of 
the  space  indicates  very  plainly  a  pleuritic  exudation ;  and  if  there  is 
extensive  dulness  in  the  left  half  of  the  chest,  if  the  diiferential  diag;- 
nosis  between  pneumonia  and  pleurisy  is  uncertain  (see  p.  158),  then 
a  decided  diminution  in  the  size  of  the  space  speaks  with  strong 
emphasis  in  favor  of  the  latter. 

AUSCULTATION    OF    THE    STOMACH. 

This  has  value  in  only  one  direction,  but  that  is  not  to  be  under- 
valued. When  palpation  is  made  by  strokes  upon  the  region  of  the 
stomach,  striking  more  or  less  strongly,  according  to  the  sensibility  of 
the  patient,  very  short  blows  with  the  tips  of  the  fingers,  we  some- 
times hear  a  splashing  which  is  loud  enough  to  be  heard  at  a  distance. 
This  results  from  a  certain  relation  between  the  fluid  and  the  gas  in 
the  stomach  even  in  health,  but  very  much  more  frequently  in  dilata- 
tion. Hence,  in  making  a  careful  examination  of  the  stomach,  we 
must  always  employ  it.  In  itself  it  does  not  indicate  anything,  even 
though  it  is  often  found  when  the  examination  is  frequently  repeated. 

If  we  apply  the  ear  when  the  stomach  is  inflated  with  carbonic  acid 


308  SPECIAL  DIAGNOSIS. 

we  shall  hear  a  loud  seething.  We  can  recognize  the  same  thing,  but 
less  distinctly,  in  dilatation  of  the  stomach  with  fermentation  of  its 
contents. 

It  is  evident  from  the  above  that  very  often  anatomical  diseases  of 
the  stomach  exist  without  any  physical  signs.  This  is  almost  always 
the  case  in  the  different  forms  of  nervous  dyspepsia,  which  are  accom- 
panied with  marked  subjective  symptoms.  Hence,  in  most  cases  of 
affection  of  the  stomach,  the  examination  of  its  contents  gives  much 
more  important  conclusions  than  the  local  examination.  Therefore, 
especial  attention  is  called  to  the  former. 

Examination  op  the  Intestines, 
inspection  and  palpation. 

In  employing  the  former,  there  must  of  course  be  illumination. 
The  patient  being  in  the  dorsal  position,  we  inspect  the  trunk  as  a 
whole,  from  a  distance ;  in  detail,  close  at  hand,  palpating  with  a  warm 
hand.  Then,  carefully  grasping  a  part,  we  notice  always  first  as  to 
the  amount  of  tenderness,  when,  if  there  is  any  suspicion  of  simula- 
tion or  exaggeration,  it  is  best  not  to  ask  whether  we  are  causing  pain, 
but  simply  to  notice  the  result  of  a  moderate  and  also  stronger  pres- 
sure. After  completing  the  first  examination,  which  gives  one  the 
bearings  of  the  case,  inspection  and  palpation  go  very  closely,  hand 
in  hand,  together ;  for  this  reason,  we  speak  of  them  together. 

Pain  produced  by  pressure  [Tenderness].  A  difi"use  dull  pain  often 
occurs  with  intestinal  catarrh.  A  like  diffuse,  but  generally  an  extremely 
severe,  pain  is  observed  with  acute  general  peritonitis.  Circumscribed 
tenderness  is  •  especially  frequent  in  the  right  iliac  fossa.  It  is  often 
quite  marked  in  ahdoyninal  typhus  [typhoid  fever],  often  more  severe 
in  intestinal  tuberculosis,  moderately  severe  in  typhlitis  and  affections  of 
the  vermiform  appendix,  in  both  the  last-named  diseases  generally  (not 
always),  in  connection  with  other  local  signs  (which  see).  Pain  in 
the  left  iliac  fossa  is  connected  with  the  descending  colon  (especially 
dysentery).  Very  circumscribed  severe  pain  shifting  about,  may 
occur  with  a  circumscribed  affection  of  the  small  intestine,  as  invagi- 
nation (see  Palpation,  Intestinal  Tuberculosis).     The  seats  of  hernia 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  309 

require  very  especial  attention.  (Works  upon  surgery  are  to  be  con- 
sulted regarding  these).  It  is  to  be  further  remarked  that  pain  in  the 
abdomen,  according  to  its  location,  may  come  from  any  of  the  organs 
contained  in  its  cavity,  and  also  from  its  walls ;  from  the  anterior 
abdominal  wall  (abscess) ;  pain  in  the  inguinal  region,  from  psoas 
abscess  in  the  iliac  regions,  from  the  sacral  spines  (inflammation, 
tumors). 

The  general  extent  of  the  abdomen  may  be  increased  by  a  layer 
of  fat,  by  gas  in  the  intestines  (intestinal  meteorism,  tympanites),  as 
it  occurs  continually,  scarcely  pathologically,  after  hearty  eating,  often 
with  a  large  development  of  fat :  but  we  may  also  have  it  in  every 
variety  of  degree  as  a  pathological  condition :  in  acute  and  chronic 
catarrh  of  the  intestine,  intestinsjl  stenosis,  in  acute  and  chronic  perito- 
nitis, and  in  abdominal  typhus  [typhoid  fever],  where  it  is  often  of 
diagnostic  value.  According  to  the  amount  of  distention,  the  abdomen 
is  more  or  less  full,  which  changes  its  normal  soft  condition  to  one  of 
marked  resistance.  When  there  is  marked  meteorism,  the  liver  and 
diaphragm  are  pressed  upon,  and  by  the  latter  the  lungs  and  heart 
are  pressed  upward. 

In  a  case  of  typhus  abdominalis  [typhoid  fever]  I  once  saw  an  ex- 
tensive inflammatory  undermining  of  the  abdominal  wall,  which  very 
closely  simulated  meteorism  by  considerably  distending  the  abdomen, 
which  proved  to  be  an  abscess  in  the  abdominal  muscle.  For  distention 
of  the  abdomen  with  fluid  and  air  in  the  peritoneal  sac,  see  Peritoneum. 

There  may  be  circumscribed  distention  of  the  abdomen  from  a  great 
variety  of  causes  :  most  frequently  from  some  condition  in  the  peri- 
toneum (which  see,  and  also  the  next  page  under  Tumors). 

Diminished  volume  of  the  abdomen  (drawing-in,  sinking-in)  results 
from  an  insufficient  amount  of  nourishment  from  any  cause  (especially 
from  diseases  of  the  oesophagus,  pyloric  stenosis,  any  cachexia — in 
short,  from  any  disease  that  requires,  or  results,  in  restricted  diet. 
Usually  this  condition  is  more  especially  manifested  by  the  absence  of 
fat  and  wasting  of  the  abdominal  muscles.  A  particularly  marked 
— the  so-called  "scaphoid" — drawing-in,  probably  related  to  an  active 
contraction  of  the  abdominal  muscles,  occurs  in  meningitis,  particularly 
basilar,  and  in  lead-colic. 

Intestinal  peristalsis  exceptionally  can  be  seen  when  the  abdominal 
wall  is  very  thin  and  lax.     It  occurs  almost  exclusively  in  women 


310  SPECIAL  DIAGNOSIS. 

who  have  had  children  (particularly  if  there  is  a  separation  of  the 
recti  muscles).  It  is  to  be  distinguished  from  its  similarity  to  what  is 
described  as  pathological  peristalsis  only  by  the  absence  of  other 
phenomena,  and  by  the  narrowness  of  the  intestinal  figure. 

Peristalsis  that  is  pathological  is  an  important  visible  and  palpable 
^ign  of  stenosis  of  the  intestine,  and  occurs  in  the  portion  of  intestine 
above  the  stenosis.  We  observe  a  round  projection,  with  the  slow 
motions  of  a  worm,  now  disappearing  and  often  immediately  reappearing 
in  a  spot  not  far  distant,  so  that  we  have  the  phenomenon  of  peristalsis. 
The  intestine,  as  it  becomes  prominent,  is  moderately  resistant,  and 
is  often  distinctly  distended.  [During  the  instant  of  greatest  disten- 
tion the  prominence  is  more  distinctly  tympanitic]  The  resistance  may 
become  greater  in  chronic  stenosis  of  the  intestine  with  hypertrophy. 
Sometimes  the  last  swelling — that  is,  the  one  just  above  the  point  of 
stenosis — is  the  largest,  and  subsides  with  a  loud  cooing  or  bursting 
sound.  This  phenomenon  may  have  a  very  great  variety  of  manifes- 
tations, generally  with  a  pressing,  choking  pain,  and  it  may  manifest 
itself  under  gentle  blows,  with  faradization,  or  even  by  merely  ex- 
posing the  surface  to  the  air.  It  is  usually  very  difficult  to  draw 
any  conclusion  regarding  the  portion  of  the  intestine  involved  by  the 
location  of  the  phenomenon  or  the  direction  of  the  peristalsis.  On 
account  of  its  thickness,  we  are  apt  to  mistake  a  dilated  loop  of  small 
intestine  for  a  portion  of  the  colon. 

Circumscribed  tumors  of  the  intestine  are  always  felt  before  they 
can  be  seen.  They  may  be  :  1.  Balls  of  feces,  scybala,  in  the  large 
intestine,  often  recognized  by  being  arranged  in  a  circular  form,  by 
their  location  (which  is  often  deceptive),  or  by  their  retaining  an 
indentation.  Sometimes  we  are  only  able  to  be  positive  regarding 
their  nature  by  their  disappearance  after  free  purgation.  2.  Tumors 
of  the  intestine  are  either  new  formations,  which  are  generally  very 
firm,  uneven,  or,  from  invagination  of  one  portion  of  the  small 
intestine  into  another  or  into  the  large  intestine,  which  are  round 
vermiform  tumors.  The  former  are  entirely  fixed,  the  latter 
may  suddenly  disappear.  Both  may  be  connected  with  signs  of 
stenosis  of  the  intestine.  If  they  belong  to  the  small  intestine,  they 
usually  more  or  less  change  their  location.  (For  distinguishing  these 
tumors  from  those  of  the  other  abdominal  organs,  of  the  peritoneum, 
and  of  the  abdominal  wall,  see  below.  For  inflammatory  tumors  of 
the  intestine,  perityphlitis,  etc.,  see  Peritoneum.) 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  311 

Tumors  of  the  rectum  cannot  be  recognized  from  the  abdomen  (see 
for  these,  below).  Those  at  the  point  of  union  between  the  transverse 
and  the  descending  colon  are  often  recognized  late,  because  they  lie 
concealed.  They  may  easily  be  confounded  with  tumors  of  the  spleen 
or  with  the  kidneys  (which  see).  In  this  connection  we  must  bear  in 
mind  the  phenomena  of  stenosis.  (For  peritoneal  friction-sounds,  see 
Peritoneum  ;  for  cooing-sounds  that  can  be  felt,  see  Auscultation  of 
the  Intestine.) 

Palpation  of  the  rectum.  The  rectum  must  be  examined  with  the 
finger  if  the  movement  of  the  bowels  or  the  character  of  the  stools 
indicate  disease  of  this  organ,  or  if  disease  in  the  neighborhood  (as  the 
wall  of  the  true  pelvis,  the  prostate  in  men,  the  uterus  and  its  annexae 
in  Avomen)  is  suspected.  In  making  the  examination,  we  first  obtain 
a  view  of  the  anus  externally  (as  to  varices,  pedunculated  new  forma- 
tions, which  sometimes  come  into  view  at  the  anus  from  above  the 
flexure,  an  external  rectal  fistula).  Sometimes  it  is  also  necessary  to 
obtain  a  thorough  emptying  of  the  bowel  beforehand.  The  index- 
finger  is  to  be  oiled  and  introduced  with  the  patient  either  lying  on 
the  side  or  back.  (For  examining  during  narcosis  by  introducing  the 
whole  hand,  see  works  upon  surgery.)  When  the  rectal  sound  is 
employed,  in  order  to  reach  a  stenosis  beyond  the  reach  of  the  finger, 
the  greatest  care  is  necessary.  It  is  best  to  employ  a  sound  open  at 
the  end,  so  as  to  throw  in  some  lukewarm  water  by  means  of  an 
irrigator,  so  that  any  obstruction  to  the  passing  of  the  sound  may  be 
gotten  out  of  the  way.  Sometimes  a  large  quantity  of  water  is  thus 
employed,  as  recommended  by  Hegar  (see  also  the  works  upon  surgery 
for  the  employment  of  the  mirror  in  making  the  examination). 

Distending  the  descending  colon  by  inflating  it  with  air  introduced 
from  the  anus  through  the  sound,  if  carefully  done,  is  not  dangerous, 
and  is  very  strongly  recommended  for  determining  the  location  of  the 
colon  with  reference  to  other  organs,  tumors  (see  spleen,  kidneys),  the 
figure  and  condition  of  the  colon  itself 

PERCUSSION    OF    THE    IXTESTUSTE. 

Generally  the  intestine  gives  a  tympanitic  sound ;  with  meteorism  with 
great  tension,  it  may  become  clear  non-tympanitic.  Over  large  intes- 
tinal loops,  and  also  over  the  stomach  (with  like  tension),  the  sound  is 


312      ■  SPECIAL  DIAGNOSIS. 

deeper  than  over  narrow  portions ;  over  lax  portions,  it  is  deeper  than 
over  those  under  strong  tension.  But  we  can  hardly  ever  determine 
as  to  the  width  of  any  portion  of  intestine  by  the  resonance,  chiefly 
because  of  the  influence  of  tension,  which,  for  a  single  loop  of  intestine, 
we  cannot  at  all  control.  Hence,  we  cannot  with  certainty  determine 
by  percussion  the  boundary  between  the  colon  and  small  intestine,  a 
dilatation  above  a  stenosis  from  another  portion,  or  intestine  from  the 
stomach.  At  most,  we  can  only  determine  the  boundary  of  the 
descending  colon  by  artificially  inflating  it. 

(For  determining  by  percussion  the  boundaries  of  the  abdominal 
organs  that  do  not  contain  air,  see  under  the  different  ones.)  Intes- 
tinal tumors  do  not  always  become  so  large  as  to  give  dulness.  In 
percussing  them,  we  first  press  tolerably  deeply  with  the  finger  used 
as  pleximeter,  and  if  we  do  not  find  dulness  we  press  still  deeper,  in 
order  that  we  may  push  aside  any  fold  of  intestine  that  may  lie  over 
the  tumor  ("deep  percussion,"  Weil). 

AUSCULTATION    OF    THE    INTESTINE. 

Borhorygmi  and  splashings,  which  may  often  be  heard  at  a  distance, 
and  are  in  themselves  very  troublesome  (especially  in  women  who 
have  had  children),  do  not  have  any  further  significance.  A  loud 
cooing  is  not  without  diagnostic  value,  if  it  occurs  at  the  close  of  an 
attack  of  pain  like  strangulation.  Even  if  we  cannot  see  any  intes- 
tinal peristalsis,  we  must  remember  the  possibility  of  stenosis  of  the 
intestine.  Although  formerly  too  much  importance  was  attached  to 
it,  yet  there  is  some  diagnostic  value  in  the  cooing,  which  is  more  fre- 
quently felt  than  seen  in  the  ileo-csecal  region  in  typhoid  fever  (ilio- 
caecal  gurgling). 

Examination  of  the  Peritoneum. 

Pathological  conditions  of  the  peritoneum  are,  in  part,  of  such  a 
character  that  they  aff"ect  the  outer  layers,  the  coverings  of  the  other 
abdominal  viscera,  hence  possible  anomalies  of  the  peritoneum  may 
be  overlooked  in  the  direct  examination.  Thus,  very  many  diseases 
of  other  abdominal  organs  are  combined  with  those  of  the  peritoneum. 
This  fact  and  the  anatomical  interrelations  of  the  diaphragm  and 
certain  other  organs  make  it  very  difficult  to  give  a  separate  descrip- 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  313 

tion  of  its  physical  diagnosis.  In  what  follows  we  mention  what  may 
be  learned  in  peritoneal  diseases  by  the  separate  methods  of  examina- 
tion, but  Ave  call  attention  to  the  point  that  the  examiner  ought  to 
learn  to  give  his  attention  to  all  the  abdominal  organs,  by  inspection, 
palpation,  etc.,  at  the  same  time. 

INSPECTION    OF    THE    ABDOMEN. 

In  diseases  of  the  peritoneum,  this  may  reveal  distention  of  the 
abdomen,  which  may  be  quite  considerable,  and  quite  like  intestinal 
meteorism.  Meteorismus  peritonei — that  is,  escape  of  air  into  the 
abdominal  cavity  from  the  intestine  or  stomach — is  a  very  serious 
condition,  which  always  results  in  peritonitis.     (See  below.) 

There  is  general,  though  often  unequal,  distention  when  there  is 
freely-movable  fluid  in  the  peritoneal  cavity:  ascites.  Such  a  fluid 
effusion  collects  in  the  most  dependent  part  of  the  abdominal  cavity, 
first  in  the  true  pelvis ;  then,  as  the  amount  increases,  it  rises  higher, 
reaching  the  abdominal  wall,  where  its  level  may  stand  at  different 
heights.  The  abdominal  organs  that  contain  air  float  upon  the  top  of 
the  fluid  so  far  as  the  peritoneal  fold  permits.  In  consequence  of  the 
increased  internal  pressure,  the  abdomen  is  broader,  and  the  lower 
part  contains  the  fluid,  while  the  intestine,  containing  air,  lies  at  the 
upper  part,  and  is  in  contact  with  the  abdominal  wall.  But  the  fluid, 
since  it  is  freely  movable,  occupies  always  the  most  dependent  part 
with  every  change  of  position  of  the  body,  and,  if  the  tension  of  the 
abdominal  wall  is  not  too  great,  there  often  results  an  unequal  disten- 
tion of  the  abdomen  which  varies  with  the  position  of  the  body.  In 
the  dorsal  position,  it  is  quite  toward  the  sides  ;  when  lying  upon  the 
side,  it  is  over  the  inguinal  and  lumbar  regions  upon  each  side ; 
while  in  the  sitting  posture,  it  fills  the  dependent  abdominal  sides,  the 
upper  portions  being  empty ;  and  in  standing,  the  lower  part  of  the 
abdomen  projects.  If  there  is  so  large  an  effusion  as  to  fill  the  abdo- 
men very  full  there  is  no  change  in  the  distention,  and  it  is  also  more 
regular,  like  that  we  have  with  marked  meteorism.  (Regarding  the 
high  position  of  the  diaphragm,  when  there  is  distention  of  the  abdo- 
men, see  Respiratory  Organs  and  Liver.) 

If  the  skin  is  examined  when  there  is  marked  effusion  it  will  not  at 
all  look  as  it  usually  does :  on  account  of  the  tension,  it  is  smooth, 


314  SPECIAL  DIAGNOSIS. 

shining,  and  shows,  especially  in  the  dependent  parts,  a  peculiar 
bluish  shimmer.  When  the  tension  is  of  long  standing,  there  are 
colorless  streaks  or  strise  which  are  formed  in  the  skin  by  the  con- 
tinuous stretching,  as  in  tlie  scars  resulting  from  pregnancy,  so-called 
from  their  chief  cause.  The  umbilicus  may  be  obliterated  or  even 
project.  In  marked  ascites,  the  cutaneous  veins  of  the  abdomen  are 
found  enlarged,  since,  as  collateral  veins,  they  must  take  up  the  over- 
flow of  the  intra-abdominal  veins,  which  are  compressed.  Under  some 
circumstances,  there  may  be  oedema  of  the  legs  from  compression  of 
the  iliac  veins.  (Regarding  the  caput  medusae  and  the  abdominal 
veins  in  general  in  cirrhosis  of  the  liver,  see  under  Liver.) 

Ascites  that  moves  about  generally  results  from  transudation  into 
the  abdominal  cavity  from  stasis,  being  rarely,  except  in  the  beginning 
of  a  disease,  dependent  upon  inflammatory  exudations.  In  the  former 
case,  it  is  either  a  partial  indication  of  general  dropsy,  and  connected 
with  oedema  (see),  or  entirely  the  result  of  obstruction  of  the  portal 
vein  (cirrhosis  of  the  liver,  compression,  and  thrombosis  of  the  vein). 
In  the  latter  case  it  is  a  sign  of  peritonitis.  (See  under  Palpation, 
Percussion.) 

Circumscribed  distention  of  the  abdomen,  where  there  has  been  little 
or  no  change  in  posture,  may  be  due  to  inflammatory  fluid  exudations, 
which  are  enclosed  between  adhesions  of  the  intestine  to  itself  or  the 
abdominal  wall,  or  by  any  kind  of  tumor  in  the  abdominal  cavity; 
and  also  by  tumors  or  abscess  in  the  abdominal  wall  itself.  Circum- 
scribed distention,  Avith  inflammatory  redness,  indicates  a  discharge 
outward  of  an  abscess,  either  fecal  or  some  other  collection  of  pus  in 
the  abdominal  cavity,  or  of  the  abdominal  wall. 

In  diseases  of  the  peritoneum,  palpation  gives  very  important  signs  : 

Pain  in  all  inflammatory  affections.  It  is  usually  very  severe  in 
a,c\xte  peritonitis,  sometimes  so  great  that  the  slightest  motion,  or  even 
the  lightest  covering  upon  the  abdomen,  cannot  be  borne.  This  sensi- 
bility is  an  important  indication  of  peritonitis,  especially  in  distinguish- 
ing the  ordinary  intestinal  meteorism  from  the  intestinal  meteorism  with 
peritonitis,  sometimes  also  in  distinguishing  inflammatory  ascites  from 
dropsical  ascites.  Circumscribed  pain  may  indicate  a  circumscribed 
peritonitis,  as  it  occurs  more  particularly  over  tumors,  abscess  of  the 
stomach  and  intestine.  In  chronic  peritonitis,  especially  in  tubercu- 
losis, sometimes  there  is  entire  absence  of  tenderness. 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  315 

Now  and  then,  in  chronic  peritonitis  there  is  a  general,  more  or  less 
symmetrical,  hardness  of  the  abdominal  wall — that  is  to  say,  it  feels  as 
if  it  were  thickened.  This  is  to  be  distinguished  from  the  general 
increased  resistance  from  tension  due  to  marked  distention  of  the 
abdomen  from  meteorism  and  ascites.  Thus,  there  is  a  marked  differ- 
ence between  the  resistance  of  fluid  and  that  of  meteorism  in  a  fold  of 
intestine.  The  latter  has  more  the  feeling  of  an  air-pillow,  the  former 
is  more  like  a  material  substance.  But  we  recognize  fluid  with  much 
more  certainty  by  the  feeling  of  fluctuation,  undulation.  A  hand  is 
laid  flat  upon  the  surface  of  the  abdomen,  and  then  the  abdominal  wall 
is  tapped  lightly  with  one  or  two  fingers,  just  as  in  direct  percussion. 
If  both  hands  are  used,  fluctuation  is  found  in  a  place  where  there 
is  an  accumulation  of  fluid,  and  the  stroke  of  the  wave  is  felt  with 
every  tap  of  the  fingers.  In  this  way  the  presence  of  even  a  small 
amount  of  fluid  in  the  abdominal  cavity  can  be  made  out  with  great 
certainty.  When  there  is  great  effusion  under  high  pressure  this 
sign  may  fail.  On  the  other  hand,  we  may  be  deceived  in  the  case  of 
persons  who  have  a  large  accumulation  of  fat  in  the  abdomen  by  the 
trembling  of  the  layers  of  fat,  and  possibly,  also,  by  the  fat  in  the 
abdominal  cavity,  in  the  omentum  especially. 

Very  much  increase  of  resistance,  and  thus  an  indistinct  fluctuation, 
generally  occurs  when  the  peritoneal  fluid  is  encysted.  Circumscribed 
hard  resistance,  now  like  a  round  ball  and  again  cord-like,  occurs  with 
extremely  great  variations  in  chronic  peritonitis,  not  alone  of  the 
tubercular  variety,  but  also  in  the  so-called  simple  peritonitis  from  in- 
flammatory new  formations ;  nevertheless,  the  former  is  usually  the 
much  more  frequent  condition.  Particularly  often  in  this,  although 
sometimes  also  in  simple  chronic  peritonitis,  we  feel  above  the  navel  a 
dense  transverse  string :  the  omentum  is  shrunken  and  thickened  by 
inflammatory  products.  Besides  there  are  usually,  but  not  always, 
the  signs  of  encysted  or  even  of  free  fluid  in  the  peritoneal  cavity. 
Exactly  the  same  phenomena  are  present  in  carcinoma  and  sarcoma  of 
the  peritoneum. 

There  occurs  in  an  acute  way  resistance  in  the  neighborhood  of  the 
caecum  in  typhlitis  and  perityphlitis.  Here  there  is  generally  a  cir- 
cumscribed globular,  or  flattened  globular,  tumor,  usually  immovable, 
which,  at  first  at  least,  is  extremely  tender.  It  indicates  a  fixed  mass 
of  feces  in  the  caecum,  or  an  inflammatory  deposit  upon  the  serous  side 


316  SPECIAL  DIAGNOSIS. 

of  the  caecum,  or  both.  In  inflammatory  cases,  there  remains  for  a 
long  time,  or  even  permanently  after  recovery,  a  dense  spot  (a  scar  from 
shrunken  inflammatory  new  formation  in  the  peritoneum).  In  inflam- 
mation of  the  vermiform  appendix,  we  can  seldom  affirm  that  there  is 
a  tumor. 

Palpation  of  the  peritoneum  through  the  vagina  in  order  to  dis- 
cover whether  there  are  tumors,  exudations  in  Douglas's  space  and 
anywhere  in  the  neighborhood  of  the  uterus,  especially  the  different 
forms  of  peritonitis,  belongs  to  gynecology.  It  is  not  necessary  to 
measure  the  circumference  of  the  abdomen  for  establishing  a  diagnosis, 
but  yet  it  is  valuable  for  the  purpose  of  observing  the  course  of  an 
abdominal  affection,  and  particularly  for  ascertaining  the  increase  and 
diminution  of  fluid  exudations.  It  is  generally  suSicient  to  measure 
the  abdominal  circumference  across  the  navel  and  the  lower  lumbar 
vertebrae.  It  is  better  also  to  measure  the  distance  between  the 
xiphoid  process  and  the  symphysis  pubis. 

Percussion  gives  valuable  information  regarding  the  peritoneum,  as 
to  whether  there  is  fluid  eff"usion  in  the  peritoneal  cavity,  its  location 
and  nature.  By  percussing  with  some  force  at  what  we  suppose  to  be 
the  boundary  line,  we  can  easily  determine  the  boundary  between  the 
dulness  of  fluid  and  the  tympanitic  resonance  of  the  intestine ;  but 
we  can  never  distinguish  it  from  that  of  those  organs  that  do  not  con- 
tain air,  as  the  liver,  spleen,  etc.  The  superior  surface  of  a  freely- 
movable  effusion  is  always  horizontal,  and  hence  its  upper  boundary 
line  must  correspond  to  a  section  of  a  horizontal  plane  drawn  through 
the  abdomen,  in  whatever  position  the  patient  may  assume.  When- 
ever the  patient  changes  his  position,  immediately  the  eff"usion  changes 
its  relations  to  the  abdominal  cavity  (see  above,  under  Inspection). 
Hence  the  result  of  percussion  changes  with  the  position  of  the  body  : 
if  the  patient  lies  upon  the  right  side,  then  the  portion  of  the  abdo- 
men which  is  now  lowest  gives  a  deadened  sound,  while  the  upper 
boundary  is  horizontal ;  in  the  left  half  of  the  cavity,  there  is  tympan- 
itic resonance ;  if  the  patient  turns  upon  the  left  side,  this  is  now  dull, 
and  the  right  is  tympanitic.  This  is  an  important  sign,  not  only  that 
the  fluid  is  movable,  but  often  that  there  is  fluid  present.  Small  effu- 
sions, which  rarely  rise  only  a  little  above  the  pelvis,  will  hence  be  first 
recognized  by  percussing  when  the  patient  stands  upright.  If  there 
is  then  dulness  above  the  symphysis  pubis,  it  immediately  disappears 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  317 

when  the  patient  lies  upon  the  back.  Very  large  eflfusions  may  fill 
the  abdomen  so  full  that  the  intestines,  on  account  of  a  short  mesen- 
tery, cannot  float,  and  hence  cannot  come  in  contact  with  the  abdom- 
inal wall.  Then  the  strongly-distended  abdomen  gives  a  dull  sound 
throughout,  and  we  sometimes  notice  a  change  of  the  boundary  of  dul- 
ness  only  in  the  position  on  the  side,  Avhen  the  upper  portion  gives  a 
clear  sound. 

When  the  fluid  moves  about  with  difficulty,  slowly  and  incompletely 
changing  its  location  with  the  change  of  position  of  the  body,  and 
still  more  if  it  is  entirely  immovable,  inflammatory  exudation  with 
glueing  or  adhesion  of  the  intestines  together  and  to  the  abdominal 
wall  is  indicated.  If  the  fluid  does  not  move  it  is  said  to  be  en- 
cysted. But  not  infrequently  even  inflammatory  exudation,  at  least 
in  the  beginning  of  its  efiusion,  is  freely  movable. 

Percussion  may  be  an  important  aid  in  recognizing  meteorismus 
peritonei  in  so  far  that  in  many  cases,  if  adhesions  have  not  already 
been  formed  before  the  occurrence  of  perforation,  it  gives  a  perfectly 
uniform  tympanitic  or,  if  the  tension  is  great,  a  non-tympanitic  sound 
over  the  whole  abdomen,  also  over  the  region  of  the  liver  and  spleen, 
and  besides,  on  account  of  the  diaphragm  being  arched  high  up,  as 
far  as  the  fifth,  or  even  the  fourth,  rib.  Not  infrequently  in  this  way 
we  obtain  Heubner's  rod-pleximeter  phenomenon  (see  p.  112). 

Subphrenic  peritonitis,  pyopneumothorax  subphrenicus  (Leyden), 
subphrenic  abscess.  We  understand  by  this  an  ichorous-purulent, 
sacculated  peritonitis  below  the  diaphragm.  From  paralysis  (partly 
also  from  destruction),  the  diaphragm  is  pushed  very  high  into  the 
thorax,  causing  a  marked  retraction  or  compression  of  the  lung  of 
that  side.  That  half  of  the  thorax  is  broadened,  and  by  the  presence 
of  pus  and  gas  in  the  cavity,  one  is  apt  to  mistake  the  condition  for 
pyopneumothorax.  Peritonitis  of  this  character  usually  begins  at  the 
stomach  as  an  ulcer,  or  at  the  intestine,  especially  at  the  vermiform 
appendix  and  caecum.  In  making  a  diff"erential  diagnosis,  we  observe 
whether,  in  the  status  proesens  or  in  the  previous  development,  there 
were  indications  of  disease  of  the  lungs  or,  on  the  other  hand,  of  the 
abdomen,  and  also  whether  the  luug  of  the  diseased  side  still  performs 
the  motions  of  respiration.  During  puncture,  it  has  frequently  been 
found  that  the  pressure  rises  during  inspiration  in  a  subphrenic  cavity, 


318  SPECIAL  DIAGNOSIS. 

while  it  falls,  of  course,  in  a  pleural  cavity.  This  can  be  recognized 
by  the  varying  rapidity  of  discharge  from  the  aperture  made  by  the 
needle,  or  by  introducing  a  manometer  into  the  cavit3^ 

The  presence  of  air  which  has  escaped  into  the  peritoneal  cavity  is 
shown  in  m^tny  cases  by  the  clear,  metallic  ringing,  intestinal  sound  in 
the  upper  part  of  the  abdominal  cavity,  sometimes  even  a  metallic, 
transmitted  breathing  sound,  which  it  yields  to  auscultation.  More- 
over, with  the  inflammatory  deposits  upon  the  reduplications  of  the 
peritoneum,  especially  over  the  liver  and  spleen,  there  occurs  syn- 
chronously with  breathing  a  peritoneal  friction  sound,  exactly  corre- 
sponding to  the  pleuritic  friction  sound.  It  is  very  rarely  produced 
by  peristalsis  over  the  intestines.  If  the  friction  sound  is  pronounced, 
it  can  also  be  felt. 

When  it  is  advisable,  as  a  therapeutic  measure,  to  draw  off  fluid  from 
the  peritoneal  cavity  by  puncture,  it  may  be  of  diagnostic  value  in  two 
ways  : 

1.  It  is  then  possible  to  examine  the  organs  in  the  abdominal  cavity, 
which  previously  were  concealed  by  the  ascites.  Not  only  does  the 
fluid  prevent  the  examination  of  the  organs  more  or  less  completely 
covered  by  it,  but  the  folds  of  the  intestine  floating  upon  it  also  do  so, 
in  that  they  crowd  in  between  certain  parts,  especially  the  liver  and 
spleen,  and  the  anterior  abdominal  wall.  When  the  abdomen  has 
been  emptied,  its  wall,  which  before  was  tensely  stretched,  is  very  lax, 
and  this  renders  the  examination  extremely  easy.  Hence  we  can 
now  usually  very  easily  discover  the  diseases  which  caused  the  effusion 
(cirrhosis  of  the  liver,  tumors,  which  press  upon  the  portal  vein  ; 
cancer  of  the  stomach,  ovarian  tumor,  etc.),  or  certain  results  of  peri- 
tonitis (bands  of  scar  tissue,  which  compress  the  intestine,  swollen 
mesentery,  etc.). 

2.  The  fluid  that  has  been  drawn  off  can  be  examined.  It  is  as 
important  to  do  this  as  to  examine  pleural  fluid  (which  see,  p.  IGO). 

The  ordinary  hypodermic  syringe,  holding  one  gramme — not  the 
one  recommended  for  puncturing  the  pleura — is  to  be  employed  for 
puncturing  the  abdomen. 

Exploratory  puncture.,  by  means  of  a  large  hypodermic  syringe,  is 
useful  in  distinguishing  encysted  peritoneal  fluid  from  the  solid  and 
fluid  contents  of  certain  tumors  (see  Abdominal  Tumors). 

Chylous  ascites  has  been  observed  in  some  cases  of  compression  of 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS. 


319 


the  thoracic  duct ;  the  ascitic  fluid  is,  to  a  varying  extent,  milk-like 

in  appearance.     It  contains  molecules  of  fat  and  a  ferment  that  forms 

sugar. 

Examination  of  the  Liver. 

Anatomy. — -The  liver,  covered  by  the  peritoneum,  lies  close  to  the 
diaphragm — within  its  arch — and  is  held  in  place  by  the  suspensory 
ligament  and  by  the  intra-abdominal  pressure  exerted  upon  its  lower 


Fig.  87. 


Location  of  thfi  thoracic  contents,  of  the  stomach,  and  of  the  liver,  from  in  front. 
("Weil-Ltjschka.)  The  unbroken  hatched  lines  represent  the  portions  of  the  heart  and 
liver  that  are  in  contact  with  the  thoracic  wall.  The  portions  of  these  organs  that  are 
not  in  parietal  contact  and  are  covered  by  the  lungs  are  represented  by  the  light  hatch- 
ing.   ef{ ),  border  of  the  right  lung;  g  h  { ),  border  of  the  left  lung;    a6,  andc«Z 

(.  .  .  .),  boundary  of  the  complementary  pleural  sinus;  i,  boundary  between  the  upper 
and  middle  lobes  of  the  right  lung;  k,  boundary  between  the  middle  and  lower  lobes; 
I,  boundary  between  the  upper  and  lower  lobes  of  the  left  lung;  w,  stomach  (greater 
curvature). 


surface.  About  three-fourths  of  it  is  in  the  right  side  of  the  body, 
and  one-fourth  in  the  left.  With  reference  to  its  superficial  topog- 
raphy, a  larger  portion  of  it  belongs  to  the  right    hypochondrium, 


320  SPECIAL  DIAGNOSIS. 

extending  into  the  epigastrium,  and  with  a  small  portion  into  the  left 
hypochondrium.  Usually  it  does  not  extend  so  far  to  the  left  as  the 
apex  of  the  heart.  Above,  the  lungs  and  heart  glide  over  it,  and  it 
glides  over  the  stomach  (see  Fig,  13,  p.  78). 

The  extent  to  which  its  surface  is  in  contact  with  the  thoracic  wall 
is  determined  by  the  relation  of  its  upper  surface  to  the  diaphragm. 
Hence,  during  expiration  it  rises  in  the  right  half  of  the  body  as  high 
as  the  fourth  intercostal  space,  and  with  its  extreme  left  end  to  the 
fifth  rib.  The  lower  border,  in  the  scapular  and  middle  axillary  line, 
stands  about  at  the  eleventh  rib,  in  the  mammillary  line,  just  at  the 
border  of  the  ribs,  then  proceeds  obliquely  upward  toward  the  left, 
through  the  epigastrium,  under  the  left  border  of  the  ribs,  and  almost 
to  the  apex  of  the  heart. 

In  the  middle  line,  it  stands  about  midway  between  the  xiphoid 
process  and  the  umbilicus.  The  gall-bladder  lies  just  where  the  lower 
border  of  the  liver  passes  under  the  right  border  of  the  ribs,  hence 
close  within  the  right  mammillary  line. 

The  organs  that  border  upon  the  liver  are  the  lungs,  heart,  and 
the  diaphragm  above,  and  the  right  kidney,  colon  and  stomach  below. 
That  portion  of  its  upper  convex  surface  which  is  not  covered  by  the 
lungs  or  heart  is  parietal.  This  parietal  portion  is  very  small  behind. 
As  it  comes  forward,  it  is  much  broader,  and  is,  for  the  most  part, 
covered  by  the  chest-wall,  except  in  the  epigastrium,  where  it  is  free 
from  its  bony  covering. 

With  children,  the  liver  is  in  all  dimensions  proportionally  larger, 
so  that  its  lower  border  is  in  the  axillary  line  below  the  border  of  the 
ribs. 

Normally,  the  liver,  strictly  speaking,  only  moves  in  connection 
with  the  diaphragm. 

INSPECTION    OF    THE    LIVER. 

This  is  made  with  the  body  in  the  dorsal  position  moderately 
elevated. 

In  the  healthy  condition,  in  adults,  absolutely  nothing  can  be  made 
out.  The  right  and  left  hypochondriac  regions  are  exactly  alike.  In 
small  children,  we  can  sometimes  notice  a  moderate  projection  of  the 
right  hypochondrium. 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS. 


321 


Projection  of  the  right  hypochondrium,' or  also  of  the  epigastrium 
and  the  region  below  the  right  border  of  the  ribs,  indicates  enlarge- 
ment of  the  liver.  This  must  be  pretty  well  marked,  in  order  to  be 
noticed  in  this  way.  Where  the  thorax  is  very  stiiF,  the  ribs  do  not 
usually  project;  but  when  the  ribs  are  very  flexible  (children,  young 
females),  where  it  can  relatively  easily  take  place,  the  projection  of 
the  abdominal  wall  is  plainer  if  the  abdomen  is  a  little  full  and  the 
covering  thin. 

Fig. 


Location  of  the  lungs,  liver,  spleen,  and  of  the  kidneys,  from  behind.   (Weil-Luschka.) 
The  liver  and  spleen  are  represented  by  the  same  liind  of  hatching  as  in  Fig.  87.     ab 

( ),  lower  border  of  the  lungs;   cd  (.  .  .  .),  complementary  space;  i  ( ),  border 

of  the  liver;  e/(.  .  .  .),  boundary  between  the  upper  and  lower  lobes  of  the  lungs; 
g,  boundary  between  the  upper  and  middle  lobes  of  the  right  lung. 


If  the  projection  is  entirely  of  the  portion  of  the  abdomen  below 
the  border  of  the  ribs,  it  points  more  to  a  displacement  of  the  liver 
downward.  There  may  be  very  marked  distention  when  an  enlarged 
liver  is  so  displaced. 

It  is  very  rare  to  see  or  to  feel  the  lower  border  of  the  liver.  But 
it  may  be,  if,  on  account  of  enlargement  or  displacement,  or  both,  it 

21 


322  SPECIAL  DIAGNOSIS. 

is  located  low  down,  and  if* the  abdominal  wall  is  thin.  We  can  then 
also  observe  how  the  border  of  the  liver  moves  downward  with  the 
motion  of  the  diaphragm  in  deep  inspiration.  For  observing  this  the 
light  must  come  from  the  head  of  the  bed. 

When  the  wall  is  very  thin,  tumors  on  the  surface  of  the  liver  in 
contact  with  the  abdominal  wall,  or  on  the  lower  surface  of  the  border, 
and  also  a  distended  gall-bladder,  can  be  seen.  With  deep  breathing, 
they  follow  the  motions  of  the  diaphragm,  and  they  transmit  the 
motions  to  tumors  of  the  stomach  or  omentum,  which  may  be 
adherent  to  them,  or,  like  them,  visible. 

Finally,  arterial  or  venous  liver-pulse  may  be  visible,  especially  the 
latter,  which  always  accompanies  enlargement  of  the  liver. 

Enlargement  of  the  liver  may  be  dependent  upon  different  diseases 
of  this  organ.  In  engorgement  of  the  liver,  especially  in  mitral 
defects  and  in  emphysema,  in  fatty  or  amyloid  liver,  or  when  it  is  due 
to  obstruction  of  the  gall-bladder,  and  in  diffuse  hepatitis,  in  certain 
acute  infectious  diseases,  the  enlargement  of  the  liver  is  tolerably 
uniform,  its  form  being  retained.  It  manifests  itself  by  its  lower 
border  moving  down  into  the  abdomen,  but,  on  the  other  hand,  the 
diaphragm  is  pressed  upward  only  when  the  liver  is  very  greatly 
enlarged,  or  when  the  general  abdominal  pressure  is  increased  (espe- 
cially in  ascites)  The  liver  is  irregularly  enlarged  in  carcinoma, 
echinococcus,  generally  in  syphilis,  and  in  abscess.  To  what  extent 
it  is  noticeable  depends  upon  the  location  of  the  swelling,  whether 
anterior,  inferior,  or  superior,  with  displacement  of  the  diaphragm. 

Downward  displacement  or  dislocation  of  the  liver  occurs  generally 
with  depression  of  the  diaphragm,  with  severe  emphysema,  with 
pleurisy  or  pneumothorax  of  the  right  side.  Left-sided  pleurisy  or 
pneumothorax,  pericarditis,  though  generally  only  to  a  slight  degree, 
press  the  point  of  the  left  lobe  of  the  liver  downward,  and  thus  the 
lower  border  of  the  liver  in  the  epigastrium  is  horizontal.  Moreover, 
under  some  circumstances  the  liver  is  pressed  downward  by  sub- 
phrenic abscess  (see  above),  which  at  the  same  time  pushes  up  the 
diaphragm.  Lastly,  here  belongs  the  "wandering"  liver,  due  to 
relaxation  of  the  suspensory  ligament  (occurring  in  women  who  have 
borne  children).  It  is  only  in  the  two  conditions  last  named  that  it 
is  not  in  contact  with  the  diaphragm. 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  323 

It  is  to  be  observed  that  the  lower  border  of  the  liver  moves  down- 
ward not  only  when  it  is  enlarged,  but  also  when  it  is  displaced. 
These  two  conditions  will  be  distinguished  chiefly  by  palpation  and 
percussion,  and  the  consideration  of  the  accompanying  conditions  of 
the  organs  in  the  chest  and  abdomen. 

Displacement  of  the  liver  upward,  can,  of  course  only  take  place 
when  the  diaphragm  is  higher  than  normal,  as  in  retraction  of  the 
lungs,  pressure  from  belo^v,  inflammatory  or  neurotic  paralysis  of  the 
diaphragm. 

PALPATION    OF   THE   LIVER. 

In  every  relation,  this  is  the  most  important  and  certain  method  of 
examining  this  organ,  and  hence  must  be  most  diligently  practised  by 
the  beginner.  It  is  best  to  have  the  patient  in  the  dorsal  position,  and 
the  abdominal  wall  as  relaxed  as  possible.  We  first  seize,  with  the  warm 
hands,  the  whole  abdominal  sac,  have  the  patient  open  the  mouth  and 
breathe  quietly.  Drawing  up  the  limbs  is  of  little  aid  and  disturbs 
the  examination.  We  very  frequently  make  use  of  deep  breathing, 
because  in  this  way  the  parts  hidden  under  the  ribs  move  deeper,  and 
the  border  or  any  small  unevenness,  etc.,  can  be  felt  more  distinctly 
as  it  moves  against  the  examining  fingers;  and  lastly,  because  the 
liver  can  be  distinguished  from  other  organs  (kidney,  colon,  omentum, 
often  stomach,  abdominal  wall)  by  its  motions  during  deep  breathing. 
By  striking  palpation  we  understand  a  brusque  stroke  with  the  tips  of 
the  fingers.  We  employ  it  in  meteorism  and  ascites  in  order  to  push 
aside  for  the  moment  a  layer  of  intestine  lying  over  the  liver  or  fluid, 
and  thus  be  able  to  reach  the  liver  with  the  tips  of  the  fingers.  (See, 
moreover,  what  is  said  on  page  318  regarding  palpation  of  the  abdomen 
after  puncture.) 

Normally,  in  the  adult,  with  the  ordinary  thickness  of  abdominal 
wall,  we  can  feel  scarcely  anything  of  the  liver.  If  there  is  a  thin 
lax  wall  (especially  in  women),  we  not  infrequently  feel  the  edge  of 
the  liver  in  the  mammillary  line  at  the  border  of  the  ribs,  seldom  also 
in  the  epigastrium,  particularly  if  it  is  pressed  down  in  deep  inspira- 
tion.    In  children  it  is  often  very  distinct. 

For  example,  we  take  a  condition  bordering  on  the  normal,  the 
so-called  constricted  liver,  a  disease  almost  without  significance.  It 
occurs  in  women  who  have  laced  themselves  very  tightly  for  a  long 


324  SPECIAL  DIAGNOSIS. 

time.  Corresponding  to  the  anatomical  condition  of  the  liver,  we  can 
feel  a  tongue-like  prolongation  of  the  right  lobe,  which  prolongation 
is  separated  from  the  mass  of  the  liver  by  a  constricting  furrow  close 
under  the  border  of  the  ribs.  Sometimes  the  constricted  liver  is  sensi- 
tive on  pressure. 

In  ascertaining  the  pathological  conditions  of  the  liver  by  palpation 
a  series  of  points  of  view  come  under  consideration : 

1.  The  existence  of  tenderness.  There  is  no  tenderness  with  the 
fatty,  amyloid,  cirrhotic  liver,  with  echinococcus  (if  there  is  no  forma- 
tion of  pus),  nor  engorged  liver  (infrequent),  if  it  has  been  for  a  long 
time  uniformly  engorged ;  the  syphilitic  liver  is  usually  not  tender, 
but  sometimes  it  is  so.  Generally,  in  the  beginning  of  cirrhosis  the 
liver  is  sensitive,  also  in  biliary  engorgement.  According  to  the  extent 
to  which  the  peritoneum  is  involved,  carcinoma  of  the  liver  may  be 
entirely  without  tenderness,  or  it  may  be  very  sensitive,  also,  when 
engorgement  of  the  liver  has  rapidly  developed,  it  may  be  very  tender. 
When  an  abscess  of  the  liver  is  parietal,  possibly  involving  the  peri- 
toneum, there  is  a  circumscribed  area  of  great  tenderness  ;  with  deep- 
seated  abscess,  there  is  no  pain.  Tenderness  of  the  liver  may,  besides, 
be  caused  by  chronic  (often  tubercular)  peritonitis,  without  there  being 
any  trouble  with  the  liver  itself. 

2.  The  size  and  form.  Depression  of  the  lower  border,  without 
change  in  form,  indicates  uniform  enlargement,  but  possibly  also  dis- 
placement. Unless  there  is  considerable  enlargement,  it  is  often 
difficult  to  distinguish  between  these  two  conditions.  If  there  is 
simultaneously  tenderness  and  hardness  (see  below),  or  if  there  are 
conditions  of  other  organs  which  make  enlargement  of  the  liver  prob- 
able, as  valvular  disease  of  the  heart  with  engorgement,  a  disease 
causing  an  amyloid  condition,  then  we  are  very  seldom  wrong  in  the 
supposition  that  there  is  an  enlargement.  On  the  other  hand,  for 
example,  the  existence  of  pleuritic  exudation,  dextra,  etc.  (see  above), 
makes  displacement  more  probable.  There  also  may  be  at  the  same 
time  enlargement  and  downward  displacement.  But  it  must  be  remem- 
bered that,  when  a  liver  is  markedly  displaced  downward,  the  impres- 
sion is  easily  made  that  it  is  also  enlarged,  because,  by  traction  about 
its  transverse  axis,  it  becomes  parietal  to  a  larger  extent. 

When  a  downward- displaced  liver  is  distinctly  movable  by  pressure 
with  the  finger,  in  such  a  way  that  in  the  dorsal  position  it  can  be 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  325 

brought  back  to  its  normal  position,  then  we  have  a  "wandering" 
liver. 

The  form  of  the  liver  is  recognized  with  varying  distinctness,  accord- 
ing to  the  increased  extent  to  which  it  lies  against  the  abdominal  wall, 
when  it  may  be  enlarged.  It  has  already  been  mentioned  under  what 
conditions  the  liver  retains  its  form.  Tumors  of  all  kinds  (espetjially 
carcinoma,  gummata,  echinococcus)  and  scars  (syphilis)  change  its 
form.  Whole  portions  of  the  parenchyma  of  the  liver  may  often,  not 
always,  be  marked  off  by  the  scars  of  syphilis  if  they  are  very  deep: 
"lobulated  liver." 

3.  Again,  the  surface  of  the  liver  can  be  judged  by  the  portion  of  the 
upper  surface  or  the  lower  border  which  is  accessible  to  palpation,  and 
we  can  do  this  best  by  moving  the  finger-tips  with  the  abdominal  wall 
back  and  forth  over  the  liver.     In  individual  cases  it  is  only  possible 
to  feel  a  portion  of  the  lower  surface.     In  engorgement  of  the  liver,  in 
fatty  liver,  in  amyloid  liver,  in  a  portion  of  the  first  stage  of  cirrhosis, 
and  in  the  so-called  hypertrophic  liver,  the  surface  will  be  found  to  be 
smooth ;  also,  in  echinococcus,  carcinoma,  and  syphilis  of  the  liver,  if 
we  palpate  a  portion  entirely  free  from  tumor  or  scars.     Small  inequali- 
ties, generally  to  a  certain  extent  uniform  over  the  whole  palpable 
portions  of  the  surface,  sometimes  so  fine  that  if  the  abdominal  wall  is 
thick  it  is  difficult  to  feel  them,  are  the  characteristic  signs  of  ordinary 
cirrhosis  of  the  liver  (interstitial  hepatitis,  granulated  liver)  toward 
the  end  of  the  first  stage  and  into  the  second.     Here,  for  two  reasons, 
it  is  usually  very  difficult  to  reach  the  liver  with  the  fingers:   first, 
because  in  the  second  stage  it  is  smaller,  and  hence  is  to  a  less  extent 
parietal,  and  second,  because  the  disease  is  commonly  associated  with 
ascites.     For  this  reason,  what  has  been  said  regarding  "stroking 
palpation  "  and  examination  after  puncture,  applies  especially  hei'e. 
It  is  further  to  be  remarked  that  the  surface  of  the  liver  in  chronic, 
and  especially  in  tubercular  peritonitis,  may  feel  tuberculated  in  conse- 
quence of  inflammatory  growths  upon  the  serous  coat,  and  this  without 
there  being  any  cirrhosis  (although  not  infrequently  this  exists  at  the 
same  time).     Large  rough  tumors,  from  the  size  of  a  cherry  to  that 
of  an  apple,  often  mingled  with  small  knots,  are  the  usual  appearances 
with  carcinoma  of  the  liver.     We  can  sometimes  recognize  upon  the 
top  of  these  carcinomatous  knots  a  depression,  the  cancer  navel ;  but 
they  are  of  neither  positive  nor  negative  diagnostic  weight.     More 


326  SPECIAL  DIAGNOSIS. 

smooth,  flat  projections,  especially  if,  besides,  we  can  feel  scar-like 
depressions,  indicate  the  presence  of  syphilitic  gummata.  Echino- 
coccus  causes  smooth  tumors  which,  according  to  their  location,  are 
flat  or  elevated,  or  they  may  even  stand  out  prominently  from  the 
surface  of  the  liver;  thus  also  abscess  of  the  liver  causes  smooth  promi- 
nences of  diff"erent  sizes  and  elevations. 

4.  The  consistence  of  the  liver  is  uniformly,  and  generally  markedly, 
increased  in  amyloid  disease,  engorged  liver,  and  in  ciiThosis.  Car- 
cinoma manifests  itself,  as  elsewhere,  usually  by  great  density. 
Abscess  of  the  liver  and  echinococcus  bladders  may  distinctly  fluctu- 
ate;  the  latter  often,  if  tightly  full,  feel  dense  as  well  as  elastic,-and 
we  can  sometimes  recognize  by  quick,  short  strokes  of  the  opposing 
hands  a  peculiar  whizzing — the  hydatid  thrill. 

In  many  cases  exploratory  puncture  will  be  indicated,  as  in  order 
to  recognize  or  exclude  echinococcus  or  abscess.  (Regarding  the 
condition  when  there  is  echinococcus,  particularly  of  the  effects, 
see  pp.  322,  325.)  Moreover,  it  is  necessary  to  compare  the 
results  of  palpation,  in  the  broad  sense  of  the  word,  with  the  accom- 
panying appearances  of  other  organs,  which  belong  to  the  individual 
diseases  of  the  liver.  These  may  stand  in  a  causal  relation  (constitu- 
tional syphilis,  primary  cancer  of  the  stomach,  etc.),  or  they  may  be 
results  (ascites  in  cirrhosis  of  the  liver  or  pressure  from  tumors,  scars 
of  the  portal  vein,  rigors  in  abscess  of  the  liver,  etc.). 

The  gall-hladder.  If  this  is  normal,  it  is  only  in  cases  of  extreme 
emaciation  that  it  can  occasionally  be  felt.  This  is  much  sooner 
possible  when  it  is  abnormally  full  of  fluid,  as  in  biliary  engorgement, 
hydrops  vesicce  fellece,  suppuration,  or  when  it  is  distended  with  gall- 
stones. In  biliary  engorgement  and  catarrhal  icterus  it  is  possible  to 
diminish  the  gall-bladder  by  carefully  compressing  it,  and  expelling 
the  contents  into  the  ductus  choledochus  and  the  duodenum.  When 
there  are  gall-stones,  if  the  abdominal  wall  is  thin,  we  sometimes  get 
the  distinct  impression  of  a  sac  filled  with  angular  stones  rubbing 
against  one  another.  A  dense,  rough  tumor  indicates  carcinoma  of 
the  gall-bladder. 

PERCUSSION    OF    THE    LIVER. 

Wherever  the  liver  is  in  contact  with  the  thoracic  or  abdominal 
wall,  we,  of  course,  have  dulness,  and  this  is  an  absolutely  deadened 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS. 


327 


sound  where  the  liver  receives  the  whole  of  the  percussion-stroke,  and 
the  stroke  is  not  permitted  to  reach  to  an  underlying  air-containing 
organ,  as  the  intestine  or  stomach.  A  relative  dulness,  with  tympanitic 
associated  sound,  occurs  when  a  thin  layer  of  liver  lies  over  the 
stomach  or  intestine,  as  is  the  case  in  the  neighborhood  of  the  lower 
border  of  the  liver.     To  a  certain  extent  it  depends  upon  the  strength 


Fig. 


Percussion  boundary  of  the  liver  in  front  (Weil). 
g  h,  the  upper  limits  of  the  lungs;  ef,  the  lower  limits  of  the  lungs;  b  d,  the  boun- 
dary between  the  lung  and  heart  at  the  incisura  cardiaca.  The  darkly-hatched  surface 
represents  the  portions  of  the  heart  and  liver  that  are  in  contact  with  the  chest- wall; 
the  light  hatchings  the  so-called  relative  heart  and  liver  deadness;  m,  spleen  deadness; 
n,  the  average  position  of  the  lower  border  of  the  stomach. 

of  the  percussion-stroke  whether  we  have  a  relative  or  an  absolutely 
deadened  sound  (see  p.  117) :  the  weaker  the  stroke,  the  sooner  do  we 
have  absolute  dulness.  The  varying  thickness  of  the  covering  of  the 
liver  is  confusing — consisting  partly  of  ribs  and  partly  of  abdominal 
wall.  Still  more  confusing  for  exact  examination  is  it  that  the  border 
of  the  arch  of  the  ribs,  at  the  most  important  point  in  the  mammillary 
line,  normally  exactly  corresponds  with  the  lower  border  of  the  liver. 


328  SPECIAL  DIAGNOSIS. 

The  difference  in  sound  which  is  caused  by  this  change  in  the  covering 
alone  obscures  the  exact  examination  of  the  liver  at  this  point. 

The  limits  of  tbe  liver,  so  far  as  they  are  determined  by  percussion, 
are  ascertained  by  gentle  percussion  at  the  right  lower  border  of  the 
lung,  by  the  transition  from  the  clear  lung-sound  (or  relative  liver- 
dulness)  to  the  absolutely  deadened  sound.  Thus,  the  upper  boundary 
of  the  parietal  part  of  the  liver  is  easily  found,  with  the  exception  of 
a  small  portion,  whore  the  liver  lies  against  the  heart  (see  Fig.  87). 
Here  we  cannot  determine  the  boundary  by  percussion,  because  the 
heart-dulness  and  liver-dulness  cannot  be  distinguished.  The  lower 
border  of  the  liver  near  the  spine  cannot  be  pointed  out,  because  it 
joins  the  kidney  (see  Fig,  88),  but  everywhere  else  its  sound  could  be 
very  easily  distinguished  from  the  tympanitic  sound  of  the  stomach 
and  intestine  if  its  anterior  part  were  not  too  sharp — that  is,  if  the 
liver  were  not  here  too  thin.  For  this  reason,  even  with  the  most 
gentle  percussion  in  the  epigastric  region,  it  is  usually  found  too  high. 
Often  no  distinct  liver-dulness  can  be  perceived  in  any  portion  of  the 
epigastrium.  Moreover,  we  must  guard  against  being  deceived  by  the 
dulness  of  one  of  the  bellies  of  the  rectus  abdominis  (lax  abdominal 
wall). 

The  relative  liver-dulness  lying  above  the  absolute  does  not  corre- 
spond to  the  anatomical  size  of  the  liver,  which  lies  much  further  back 
than  this,  as  is  shown  by  a  comparison  of  the  anatomical  figure  Avith 
the  boundary  as  determined  by  percussion.  This  is  because  the  lung 
becomes  thinner  at  its  lower  border ;  moreover,  it  is  only  anteriorly 
and  at  the  side  that  it  is  always  distinctly  present.  It  usually  fails 
between  the  scapular  line  and  the  spine,  owing  to  the  thick  wall  and 
the  diminished  sharpness  of  the  edge  of  the  lung. 

Mode  of  procedure :  We  percuss  strongly  or  lightly  down  a  known 
vertical  line  on  the  thorax,  for  determining  the  beginning  of  relative 
liver-dulness,  and  thus  fix  the  lung-liver  boundary — that  is,  the  transi- 
tion from  the  relative  to  the  absolute  liver-deadness.  Then  we  percuss 
downward,  through  the  extent  of  liver-dulness,  until  by  the  gentlest 
percussion,  we  get  the  entirely  pure  tympanitic  sound.  From  this 
point  we  go  again  upward  till  we  get  the  first  indication  of  relative 
dulness.  We  determine  the  exact  boundary  lines  by  exclusion  (see 
p.  117). 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  329 

The  average  boundary-lines  of  the  liver,  as  determined  by  percus- 
sion, are  about  as  follows  : 

The  upper,  the  lung-liver  boundary  :  Middle  line,  base  of  the  ensi- 
form  cartilage ;  mammillary  line,  sixth  rib  ;  middle  axillary  line,  eighth 
rib  ;  scapular  line,  tenth  rib. 

The  heart-liver  boundary  cannot  be  determined  by  percussion,  but 
it  lies  near  the  apex-beat. 

The  lower,  the  liver-stomach  (intestine)  boundary :  Left  of  the 
middle  line,  toward  the  half-moon-shaped  space,  ascending  obliquely 
to  about  the  sixth  rib  in  the  parasternal  line  ;  middle  line,  not  lower — 
often  higher — than  midway  between  xiphoid  process  and  the  umbili- 
cus ;  mammillary  line,  at  the  bend  of  the  ribs  ;  middle  axillary  line, 
the  tenth  rib  ;  scapular  line,  the  eleventh  rib. 

But  from  these  there,  is  frequently  a  considerable  departure,  even 
normally.  Throughout,  the  lower  boundary  has  been  found  much 
higher,  this  being  caused  by  a  fold  of  intestine  lying  over  the  liver 
and  thus  diminishing  the  extent  to  which  it  is  parietal.  This  is  par- 
ticularly the  case  with  the  ugly,  but  not  pathological,  form  of  the 
thorax  where  it  is  short  and  its  lower  aperture  is  quite  wide ;  also,  in 
persons  who  have  a  full  abdomen.  In  this  way  the  liver-dulness  may 
sometimes  be  entirely  wanting :  at  the  upper  boundary  of  the  half- 
moon-shaped  space  we  pass,  in  percussing,  from  lung-sound  into 
tympanitic  resonance. 

Extreme  elevation  of  the  liver-dulness,  although  very  variable  within 
normal  limits,  is  not  at  all  applicable  in  diagnosis. 

Mobility  of  the  boundaries  of  the  liver.  In  deep  breathing,  there 
is  a  more  marked  active  displacement  of  the  upper  boundary  (corre- 
sponding to  the  respiratory  excursion  of  the  border  of  the  lung)  than 
of  the  lower,  which  displacement  is  the  expression  of  the  movement 
of  the  dome  of  the  diaphragm.  As  regards  passive  movement,  we 
only  notice  that  in  the  left-side  position  both  boundaries  move  down- 
ward, the  upper  distinctly  so  (see  Lungs) ;  the  lower,  very  little. 

Pathological  Relations. — 1.  The  upper  boundary  of  dulness  is 
found  higher.  The  cause  of  this  can  first  of  all  be  found  in  the 
pleural  cavity  :  pleural  exudation,  tumors  of  the  pleura,  of  the  lungs, 
pneumonia ;  or  in  the  chest  wall :  tumors,  peripleuritis.  Then,  of 
course,  it  is  not  possible  to  distinguish  the  dulness  of  what  lies  above 
the  liver  from  that  of  the  liver  itself,  since  two  media  that  on  per- 


330  SPECIAL  DIAGNOSIS. 

cussion  give  dulness  cannot  be  distinguished  from  one  another.  If 
there  is  exudative  pleuritis  upon  the  right  side,  the  diaphragm  is  deeper 
and  the  liver  moves  down,  causing  its  lower  boundary  of  dulness  to  be 
lower,  and  thus  in  this  disease  there  may  be  an  extensive  dulness, 
reaching  from  high  in  the  thorax  to  far  below  the  border  of  the  ribs — 
dulness  of  the  exudation  plus  liver- dulness. 

If  the  conditions  just  named  are  excluded,  then  we  may  have 

{a)  Displacement  of  the  liver  upward,  with  high  position  of  the 
diaphragm.  Then,  at  the  same  time,  the  lower  border  of  the  liver  is 
higher,  and  indeed  the  latter  is  displaced  upward  further  than  the 
former,  because  the  liver,  as  it  moves  upward,  in  a  sense  turns  on  its 
axis — that  is,  the  lower  border  turns  up,  so  that  it  is  to  a  less  extent 
parietal — the  square  position  of  Frerichs.  (For  the  conditions  which 
displace  the  liver,  see  above.) 

(6)  A  tumor,  of  the  convexity  of  the  liver,  as  a  new  formation, 
an  abscess,  echinococcus,  when  the  upper  boundary  of  dulness  pur- 
sues an  irregular  course,  according  to  the  form  of  the  tumor ;  or  a 
subphrenic  abscess.  In  these  cases,  the  liver  is  usually  displaced 
downward,  often  very  markedly  so  ;  hence,  the  lower  boundary  of  the 
liver  at  the  same  time  stands  deeper. 

(e)  A  simultaneous  general  enlargement  of  the  liver.  This  is  rare, 
occurring  only  when  the  liver  is  very  large.  Here  also  the  lower 
boundary  of  dulness  is  considerably  deeper.  It  is  often  very  difficult 
to  distinguish,  and  then  only  by  inspection  (projection)  and  palpa- 
tion of  the  surface  and  consistence  of  the  liver,  and  other  evidences 
of  disease  referred  to  under  (6). 

2.  The  upper  boundary  of  dulness  is  found  deeper.     This  occurs  : 

(a)  With  a  simultaneous  normal  position  of  the  lower  boundary,  in 
slight  substantive,  and  in  vicarious,  emphysema.  Although  in  this  case 
the  lung  moves  down  into  the  complementary  space,  and  thus  covers 
the  liver  somewhat  more  than  is  normal,  yet  the  dome  of  the  diaphragm 
does  not  become  deeper. 

[h)  With  simultaneous  downward  displacement  of  the  lower  boun- 
dary :  low  position  of  the  diaphragm  with  the  liver :  marked  emphy- 
sema with  low  position  of  the  diaphragm  ;  pneumothorax.  We  can 
have  the  same  percussion  result  with  considerable  emphysema  and  en- 
largement of  the  liver.  Finally,  there  may  be  low  position  of  both 
boundaries  resulting  from  the  low  position  and  enlargement  of  the 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  33I 

liver,  as  is  a  frequent  occurrence  in  severe  emphysema,   because  of 
the  existing  eno;ora;ement  of  the  liver. 

When  the  liver  is  displaced  downward  it  easily  gives  the  impression 
of  being  enlarged  without  such  being  the  fact,  because  it  is  often 
parietal  for  a  larger  area  than  is  normal.  Also,  for  this  reason,  the 
liver-dulness  is  higher  than  it  is  normally  on  the  average;  especially 
in  pneumothorax  is  it  often  distinct. 

3.  The  behavior  of  the  lower  boundary  when  the  upper  is  displaced 
has  in  general  been  already  mentioned.  It  remains  to  be  noticed  that, 
when  the  liver  is  pushed  down  by  a  thoracic  affection  on  the  right  side 
[pleurisy,  pneumothorax),  it  stands  obliquely,  that  is,  the  right  lobe 
is  deeper  than  the  left,  hence  the  depressed  lower  boundary  of  dulness 
stands  steeper  than  normal,  sloping  from  the  right  toward  the  left.  On 
the  other  hand,  when  we  have  a  pleurisy  or  pneumothorax  upon  the 
left  side,  or  marked  pericarditis  exudativa,  since  the  left  end  of  the 
liver  (loh.  sinistra)  is  then  alone  pressed  down,  the  lower  line  of  dulness 
is  found  more  horizontal. 

With  a  normal  upper  border,  the  lower  boundary  stands  deep  and 
reaches  further  into  the  half-moon- shaped  space  when  the  liver  is  en- 
larged; on  the  other  hand,  it  is  higher  than  normal,  under  some  circum- 
stances even  until  the  liver  dulness  completely  disappears  in  the 
following  conditions  :  (a)  If  the  liver  is  smaller,  as  in  cirrhosis,  acute 
yellow  atrophy,  here  occurring  rapidly.  (5)  As  happens  much  more 
'frequently  than  (a),  in  case  the  liver,  though  perfectly  sound,  is  less 
parietal  than  normal,  or  is  not  at  all  so,  as  in  those  who  are  on  the 
whole  well,  in  meteorism,  ascites,  entrance  of  air  into  the  peritoneum. 
In  this  way  even  an  enlarged  liver  may  elude  examination.  In  yet 
two  Other  rare  cases  is  the  liver  dulness  entirely  wanting ;  in  situs 
inversus  viscerum  and  in  cases  of  "wandering  liver."  With  the 
latter,  sometimes  a  portion  of  the  upper  surface  of  the  liver  will  be 
found  in  contact  with  the  abdominal  wall  further  down. 

Apparent  low  position  of  the  lower  border  occurs  when  there  is  an 
airless  mass  below  the  liver,  as  with  a  full  colon,  or  a  large  tumor 
of  the  colon,  of  the  omentum,  or  of  the  stomach,  although  these  are 
rare. 

The  form  of  the  lower  border  departs  from  the  normal  when  there 
is  unequal  enlargement  of  the  liver  (see  above) ;  also  sometimes  in 
marked  enlargement  of  the  gall-bladder,  seldom  determined  by  per- 


332  SPECIAL  DIAGNOSIS. 

cussion.  (For  the  different  kinds  of  enlargement,  see  under  Palpa- 
tion.) 

4.  Relative  liver-dulness  is  diagnostically  of  little  interest.  It  is 
relatively  high,  if  the  diaphragm  rises  steeply  upward  and  inward 
from  the  thoracic  wall,  and  very  low,  if  the  diaphragm  goes  off  per- 
pendicularly from  the  thoracic  wall,  as  in  severe  emijliysema,  but 
especially  in  pneumothorax. 

All  in  all,  percussion  of  the  liver,  when  rightly  performed  and  cor- 
rectly interpreted,  is  of  very  great  value.  But  where  palpation  can 
be  employed,  as  is  usually  the  case  whenever  the  inferior  border  of 
the  liver  is  lower  than  normal,  it  must  yield  to  the  latter  method  of 
examination,  which  is  more  anatomical  and  hence  more  exact.  If  the 
border  of  the  liver  can  be  felt,  then  we  note  its  course  upon  the  body 
by  the  results  of  palpation  and  not  of  percussion,  and  proceed  with 
the  diagnosis  in  accordance  with  this  position. 

Examination  of  the  Spleen. 

Anatomy. — The  spleen,  a  long,  generally  almost  oval,  organ,  lies 
in  the  left  hypochondrium,  between  the  ninth  and  eleventh  ribs,  in 
such  a  way  that  its  long  diameter  in  the  dorsal  position  of  the  body 
lies  almost  exactly  behind  and  parallel  to  the  tenth  rib.  Its  posterior 
end  lies  about  two  centimetres  from  the  tenth  dorsal  vertebra ;  its 
anterior  end,  normally,  scarcely  reaches  to  a  line  drawn  from  the  tip 
of  the  eleventh  rib  to  the  left  sterno-clavicular  articulation  {linea 
costo-articularis),  at  any  rate  does  not  pass  beyond  it.  The  upper 
(anterior — upper  ^)  of  the  two  borders  of  the  spleen  exhibits  one  or 
two  notches. 

The  spleen  lies  close  to  the  under  surface  of  the  diaphragm,  in  the 
periphery  of  that  portion  which  rises  sharply  upward,  and  toward  its 
inner  lower  end  it  covers  a  small  portion  of  the  upper  part  of  the  left 
kidney,  also  the  colon  and  stomach.  Topographically,  with  reference 
to  the  thorax,  its  location  is  as  follows :  Its  upper  third,  during  moderate 
respiration,  is  covered  by  the  lung.     The  lower  two-thirds  are  in  con- 

1  In  what  follows  I  designate  the  two  borders  of  the  spleen  as  "  upper  "  and  "  lower," 
because  from  the  topographical  standpoint  that  always  seems  to  me  the  most  natural. 
We  speak  of  an  upper  and  lower  border  of  all  the  ribs,  even  of  the  lower  ones,  which  are 
oblique.  I  cannot  understand  why  one  of  the  two  ends  of  the  spleen  should  be  called 
the  "  upper"  and  the  other  the  "  anterior,"  as  is  done  by  Weil. 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS. 


333 


tact  with  the  thoracic  wall,  but  it  changes  its  relation  somewhat  with 
the  position  of  the  body  by  reason  of  the  passive  mobility  of  the 
border  of  the  lung  (which  see).  Its  upper  border  follows  the  ninth 
rib,  forms  the  outer  boundary  of  the  "half-moon-shaped  space,"  and 


Fig.  90.. 

€  S  A         Se 


M 


S  \ 

Position  of  the  spleen.  (Weil.)  M,  the  middle  line  of  the  back;  A,  B,C,  the 
axillary  lines;  >S'c,  the  scapular  lines;  abed,  spleen;  abc'  d,  unusual  rhomboidal  form 
of  the  spleen;  efg,  outer  boundary  of  the  kidney ;  I  b  c,  the  spleen-lrng  and  dh  g,  the 
spleen-kidney  angle;  n  m,  the  lower  border  of  the  liver. 

stands  at  a  sharp  angle  with  the  lower  border  of  the  lung  (see  figure), 
called  the  spleen-lung  angle,  whose  apex,  in  the  upright  position,  is 
about  at  the  posterior  axillary  line,  but  when  in  the  right-side  position, 
in  consequence  of  the  movement  downward  of  the  lower  border  of  the 
lung,  it  moves  somewhat  forward,  even  as  far  as  the  anterior  axillary 
line.  Its  lower  border  follows  the  eleventh  rib,  and  for  the  most  part 
bounds  the  left  kidney. 

The  spleen  is  in  parietal  contact  only  in  its  lower  two-thirds,  but  it 
cannot  be  reached  by  the  finger  except  sometimes  by  turning  the 
abdominal  wall  under  the  border  of  the  ribs. 


334  SPECIAL  DIAGNOSIS. 

INSPECTION    OP    THE    SPLEEN. 

In  the  normal  condition,  and  even  when  greatly  enlarged,  inspec- 
tion of  the  spleen  gives  no  result.  A  very  considerable  enlargement 
causes  a  projection  of  the  left  hypochondrium.  and  of  the  abdominal 
region  obliquely  inward  and  downward  from  it.  When  the  abdominal 
wall  is  thin,  the  border  of  the  enlarged  organ  or  a  circumscribed 
swelling  on  its  parietal  surface  may  be  seen.  Then  if  the  upper  end 
of  the  spleen  has  not  left  its  place  close  to  the  diaphragm  (see  below), 
it  usually  plainly  descends  with  deep  inspiration. 

PALPATION    OF    THE    SPLEEN. 

Palpation  is  very  much  the  most  important  method  of  examination, 
because  its  results  are  much  more  reliable  than  is  the  case  with  per- 
cussion. Ordinarily,  in  order  to  employ  palpation,  it  is  necessary  for 
the  patient  to  assume  what  is  called  the  diagonal  position  on  the  right 
side,  that  is  to  say,  a  position  midway  between  the  dorsal  and  the  right- 
side  position,  and  also  for  the  reason  that  percussion  can  be  practised 
very  much  better  in  this  position,  and  because  the  unity  of  the  position 
is  useful  for  comparing  the  results  of  the  two  methods  of  examination. 
When  the  patient  is  very  sick,  it  is  better  to  palpate  in  the  dorsal  posi- 
tion. When  the  spleen  is  of  very  considerable  size,  this  is  also  best 
(then,  too,  it  is  preferable  for  percussion).  If  it  is  difficult  to  find  the 
spleen,  then  we  try  the  right-side  position,  because  this  more  fully 
relaxes  the  left  side  of  the  abdominal  wall.  If  we  have  the  patient 
take  several  deep  inspirations,  a  slight  swelling  of  the  spleen  can 
usually  be  made  out  by  feeling  the  anterior  end  of  the  organ  close 
to  the  border  of  the  ribs,  at  about  the  tenth  rib,  where  it  comes  in 
contact  with  the  tip  of  the  finger.  Without  further  investigation 
we  cannot  refer  a  simple  increase  of  resistance  at  the  edge  of  the 
ribs  to  the  spleen ;   but  we  must  further  seek  to  feel  its  border. 

The  spleen  can  be  felt : 

1.  In  individual  cases  in  health,  when  the  abdominal  wall  is  very 
lax  ;  also,  sometimes,  in  persons  with  deformed  chest  (kypho-scoliosis). 

2.  If  it  is  enlarged.     It  may  be  enlarged  and  yet  retain  its  form. 
■  It  is  uniformly  enlarged  in  certain  acute  infectious  diseases,  as  in  ty- 
phoid, exanthematous  and  recurrent  fever  ;  in  scarlet  fever,  usually  in 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  335 

severe  smallpox ;  malaria,  here  relatively  very  large ;  in  erysipelas, 
here  often  very  little  enlarged ;  in  sepsis  and  pyaemia ;  sometimes  in 
acute  miliary  tuberculosis ;  in  engorgement  of  the  spleen,  especially 
in  cirrhosis  of  the  liver ;  in  occlusion  of  the  portal  vein ;  in  general 
venous  engorgement ;  in  amyloid  disease  of  the  spleen  ;  in  leuksemia 
(greatest  enlargement),  and  in  splenic  angemia ;  sometimes,  in  infarc- 
tion of  the  spleen  (heart  disease) ;  and  also  in  tubercular  peritonitis. 
We  must  here  also  mention  the  apparent  enlargement  of  the  spleen 
where  there  are  thick  peritoneal  deposits  (perisplenitis). 

It  may  also  be  unequally  enlarged  by  new  formations,  especially 
by  carcinoma,  and  by  echinococcus  and  abscess. 

8.  It  may  be  felt  if  it  is  displaced,  with  low  position  of  the  dia- 
phragm (rare);  the  "  wandering  "  spleen. 

In  palpating  we  take  notice  of: 

Pain.  Tenderness,  probably  always  from  the  peritoneum,  some- 
times occurs  in  acute  infectious  diseases,  in  suddenly  developed  engorge- 
ment, in  infarction  of  spleen,  new  formations,  abscesses.  There  may 
sometimes,  in  abscesses  and  infarction,  be  tenderness  to  pressure  upon 
the  ribs  in  the  neighborhood  of  the  spleen. 

Size.  The  largest  tumors  of  the  spleen,  often  reaching  into  the 
right  side  of  the  abdomen,  occur  in  leukgemia.  On  the  other  hand, 
in  the  acute  infectious  diseases,  we  have  moderate  enlargement  of  the 
spleen,  which  does  not  come  below  the  border  of  the  ribs.  In  other 
diseases  the  splenic  tumor  varies  very  much  in  size.  Pulsating  splenic 
tumor  has  been  observed  now  and  then  in  cases  of  aortic  insufficiency. 

Consistence.  As  a  rule,  the  consistence  increases  with  the  size, 
and  is  more  dense  in  chronic,  than  in  acute,  cases.  Generally,  the 
consistence  is  not  a  guide  in  diagnosis. 

Form,  surface.  It  has  already  been  mentioned  in  what  diseases 
the  spleen  is  uniformly,  and  in  what  unequally,  enlarged.  In  diseases- 
of  the  first  group,  we  can  almost  always,  and  in  the  latter  sometimes, 
feel  distinctly  the  notches  in  the  upper  border,  if  the  spleen  projects 
far  enough  beyond  the  border  of  the  ribs.  In  carcinoma,  the  surface 
shows  hard,  uneven  tumors ;  in  echinococcus,  they  are  round,  tense, 
elastic.  But  in  leukaemia,  the  surface  is  not  always  uniform,  for  it 
may  sometimes  exhibit  flat  elevations. 

Mohility.  We  have  already  mentioned  the  downward  movement  of 
the  spleen  with  deep  inspiration.     I  have  seen  cases  of  very  great 


336  SPECIAL  DIAGNOSIS. 

enlargement  of  spleen  where  this  did  not  take  place,  because  the 
spleen  had  pushed  the  diaphragm  high  up  on  the  left  side  (see  Percus- 
sion), and  hindered  its  contraction. 

Wandering  spleen,  having  dimirfished  respiratory  movement,  but 
passively  movable,  and  sometimes  even  showing  displacement  down- 
ward with  change  of  posture,  occurs  only  in  women.  The  spleen  may 
wander  astonishingly  far  from  its  place,  even  into  the  true  pelvis,  and 
it  has  been  found  in  the  abdominal  cavity  entirely  free  from  its  attach- 
ments ;  but  usually  there  is  only  slight  displacement.  Tumors  of  this 
kind  are  recognized  as  wandering  spleen  by  their  form  and  by  the 
notches.  Often,  it  is  at  the  same  time  enlarged.  A  spleen  displaced 
by  the  low  position  of  the  diaphragm  can  seldom  be  felt.  (See  farther 
regarding  displacement,  under  Percussion  of  the  Spleen.) 

Relation  of  the  colon  to  the  spleen.  Enlarged  and  wandering 
spleen  lies  in  front  of  the  colon.  We  can  best  prove  this  by  inflating 
the  colon  with  air  in  connection  with  palpation  and  percussion. 

PERCUSSION    OF    THE    SPLEEN. 

Percussion  is  limited  to  that  portion  of  the  spleen  which  is  not 
covered  by  the  lung  (Weil).  It  is  bounded  above  by  the  lung ;  toward 
the  front  superiorly,  we  have  the  upper  border,  inferiorly,  the  anterior 
end,  and  a  portion  some  distance  behind  (inferior  border),  against  the 
stomach  and  intestine;  further  back,  against  the  kidney.  But  this 
latter  portion  cannot  be  defined,  there  being  dulness  against  dulness. 

When  we  can  only  percuss  with  the  patient  in  one  position,  as 
with  very  sick  patients,  we  do  so  in  the  right  diagonal  posture. 
But  if  we  wish  to  be  very  exact,  and  the  patient  can  bear  it,  it  is 
best  also  to  percuss  in  the  upright  posture.  Let  it  be  repeated,  that 
palpation  generally,  even  though  the  physician  be  skilful  in  per- 
cussion, gives  a  much  more  certain  result.  But  percussion  must 
never  be  omitted.  When  the  spleen  is  very  much  enlarged,  we  may 
examine  the  patient  in  the  dorsal  position.  The  diagonal  posture  is 
only  required  to  determine  whether,  and  how  much,  the  spleen  pushes 
up  the  diaphragm. 

'  In  both  the  diagonal  and  the  upright  posture,  we  begin  by  determining 
the  lower  border  of  the  left  lung.    It  is  normally  in  the  upright  position : 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS. 


837 


Fig.  fll. 


—  <2 


mammillary  line,  sixth  rib;  middle  axillary  line,  eighth  rib;  scapular 
line,  tenth  rib.  In  the  diagonal  position,  it  varies  from  the  seventh 
to  the  eleventh  rib.  From  here,  if 
we  percuss  in  the  vertical  line,  over 
the  border  of  the  lung  downward, 
and,  in  the  diagonal  position,  about 
in  the  anterior  or  middle  axillary 
line,  below  the  border  of  the  lung, 
we  will  meet  dulness  instead  of  the 
tympanitic  sound  of  the  half-moon- 
shaped  space :  spleen-dulness.  The 
place  at  the  border  of  the  lung 
where  the  dulness  is  met  with  is  the 
apex  of  the  spleen-lung  angle  (see 
anatomy,  p.  333).  We  now  per- 
cuss vertically  downward,  through 
this  angle  beyond  the  deadened 
sound,  till  we  come  to  a  tympanitic 
(intestinal)  resonance :  the  boundary 
line  is  the  lower  border  of  the 
spleen.  Then  we  percuss  from  the 
half-moon-shaped    space   and    from 

the  abdomen,  upon  lines  which  cross  what  we  suppose  to  be  the  area  of 
spleen-dulness,  and  thus  ascertain  where  the  tympanitic  stomach  or 
intestinal  resonance  changes  to  dulness.  This  marks  the  line  of  the 
spleen.  If  we  mark  these  points,  and  connect  them,  we  obtain  the 
figure  of  the  parietal  portion  of  the  spleen,  which  we  can  complete  by 
determining  the  lower  border  of  the  spleen  in  the  posterior  axillary 
line,  or  in  a  vertical  line  between  this  and  the  scapular  line. 

In  the  upright  position,  the  conditions  are  altered  in  such  a  way 
that  the  border  of  the  lungs,  and  with  it  the  lung-spleen  boundary, 
stands  somewhat  higher  (see  above),  and  hence  we  find  the  apex  of 
the  lung-spleen  angle  in  the  middle  or  posterior  axillary  line. 

As  has  already  been  said,  the  size  of  the  spleen-dulness,  with 
careful  percussion  and  under  favorable  conditions  (see  below),  cor- 
responds to  the  parietal  part  of  the  spleen.  From  this  we  must 
estimate  the  size  of  the  spleen.  In  measuring  it,  we  have  only  two 
points  of  departure :   the  height  of  the  spleen-dulness  in  the  vertical 

22 


jhape  of  the  spleen-deadness. 


338  SPECIAL  DIAGNOSIS. 

line  passing  through  the  apex  of  the  spleen-lung  angle,  and  the  rela- 
tion of  the  anterior  end  of  the  spleen  to  the  liyiea  costo-articularis. 
The  average  in  health  has  been  found  to  be  (Weil) : 

In  the  diagonal  posture,  the  height  of  the  spleen  is  5.5  to  7  cm.,  the 
anterior  end  at  most  reachino;  to  the  linea  costo-articularis. 

In  the  upright  position,  the  height  is  4,5  to  6  cm.,  the  anterior  end 
under  some  circumstances  passing  a  little  beyond  the  linea  costo- 
articularis:  the  spleen-lung  angle  more  pointed — that  is,  the  spleen  is 
a  little  more  horizontal. 

We  are  interested  in  the  mobility  of  the  spleen-dulness  in  deep 
inspiration  only  so  far  as  it  affects  the  boundary  between  the  spleen 
and  lung  (see  what  has  been  said  regarding  active  mobility  of  the 
border  of  the  lung). 

Weil,  in  his  work  upon  Topographical  Percussion,  has  sufficiently 
explained  why  we  must  forego  the  determination  of  the  portion  of  the 
spleen  which  is  covered  by  the  lung. 

In  the  first  place,  we  percuss  tolerably  strongly.  If  in  that  way 
we  obtain  no  result,  we  then  percuss  very  lightly.  With  strong  per- 
cussion over  the  spleen,  we  very  seldom  get  resonance;  also,  with 
moderately  strong,  only  rarely  absolute  deadness.  Also,  we  must 
often  be  satisfied,  by  gentle  percussion,  with  a  relative  dulness,  asso- 
ciated with  tympanitic  accompaniment. 

Departures  from  what  has  been  called  the  "average"  in  health : 
(a)  The  dulness  of  the  spleen  is  only  approximated  as  regards  size  or 
intensity:  a  very  frequent  occurrence  when  it  is  covered  by  intestine, 
or  the  spleen  is  thin  and  the  intestines  nea,r  it  are  distended  by  gas. 

(5)  The  area  of  spleen-dulness  is  larger,  while  its  form  is  retained  or 
is  changed :  this  occurs  when  the  stomach  is  overloaded  with  food, 
when  there  are  fecal  masses  in  the  neighboring  colon,  when  there  is 
corpulence  (the  greater  omentum  loaded  with  fat)  ;  but,  also,  some- 
times without  these  conditions  being  present.  We  must  guard  against 
deception  as  respects  the  stomach  and  intestine  by  repeated  examina- 
tions, especially  with  abstinence  from  food  and  after  free  purgation. 
When  there  is  obesity,  we  ought  not,  on  the  whole,  to  draw  any  con- 
clusion from  a  large  area  of  spleen-dulness. 

But,  at  any  rate,  we  must  never,  by  a  single  examination,  diagnos- 
ticate a  spleen-tumor  from  percussion  alone. 

Pathological  Relations. — As  mentioned  above,  diminution  of 
spleen-dulness  is  often  met  with  in  health.    In  sickness,  it  occurs  from 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  339 

overlapping  of  the  spleen  from  above  by  the  lung :  this  happens  with 
emphysema  of  the  lung,  when  the  lung  spreads  into  the  comple- 
mentary space ;  sinking  down  of  the  lower  border  of  the  spleen  and 
its  anterior  end,  as  evidence  of  displacement  downward  by  flattening 
of  the  diaphragm,  but  in  emphysema  this  cannot  be  proved.  There 
is  always  diminution  of  spleen-dulness  (even  to  complete  disappear- 
ance) Avhen  it  is  displaced  upward,  as  in  shrinking  after  pleurisy, 
contraction  of  the  lung,'  high  position  of  the  diaphragm.  Here, 
generally,  there  is  no  spleen-dulness  at  all,  on  account  of  the  intestine 
lying  over  it. 

Mnlargertient  of  spleen-dulness.  If  we  make  out  such  a  condition 
we  ought  to  call  to  mind  the  sources  of  error  mentioned  above.  We 
should  never  make  the  diagnosis  of  enlarged  spleen  from  a  single 
percussion,  without  the  support  afforded  by  palpation.  We  must 
notice  whether  the  enlarged  dulness  shows  the  relations  of  the  figure 
of  the  spleen  ;  if  it  does,  then  it  is  quite  probable  that  the  spleen  is 
enlarged ;  likewise,  if  the  examination  in  the  diagonal  and  the  standing 
position  shows  a  similar  result,  with  change  of  dulness  that  distinctly 
corresponds  with  the  changed  position  of  the  border  of  the  lung  and 
the  spleen. 

Enlargement  of  the  spleen  is  to  be  assumed  when  the  vertical 
measurement  of  dulness  is  as  much  as  9  cm.  or  more ;  also,  if  the 
area  of  dulness  extends  considerably  beyond  the  linea  costo-articularis  ; 
and,  lastly,  if  the  dulness  is  very  decided,  with  moderately  strong 
percussion  absolute.  When  there  is  considerable  enlargement  of  the 
spleen,  the  area  of  dulness  upward  is  larger,  and,  hence,  the  diaphragm, 
and  with  it  the  border  of  the  lung,  moves  higher  in  the  chest.  More- 
over, in  every  upward  enlargement  of  the  spleen-dulness  it  is  to  be 
remembered  that  it  may  be  merely  apparent,  being  caused  by  pleuritic 
exudation,  infiltration  of  the  lungs,  or  pleural  tumor. 

When  there  is  a  decided  enlargement  of  the  spleen,  it  considerably 
diminishes  the  half-moon-shaped  space.  If  there  is,  simultaneously, 
tumor  of  spleen  and  liver,  the  space  may  be  entirely  deadened. 

AUSCULTATION    OF   THE    SPLEEN. 

In  rare  cases,  auscultation  enables  us  to  recognize  peritoneal  friction-, 
sounds  should  there  be  inflammatory  deposits  upon  the  serous  coat  of  the 


340  SPECIAL  DIAGNOSIS. 

spleen  and  the  parietal  portion  of  the  peritoneum  opposite  to  it^ 
if  the  diaphragm  is  not  paralyzed  by  the  peritonitis  or  the  spleen  has 
not  become  adherent.  Peritoneal  friction-sound  over  the  spleen  (and 
over  the  liver)  seems  to  me  to  have  greater  weight  as  evidence  that 
the  first  of  the  two  last-named  conditions  is  wanting,  than  as  the  sign 
of  peritonitis,  for  the  latter  usually  appears  to  be  plainer  from  other 
symptoms.  It  may  easily  happen  that  we  find  it  difficult  to  distin- 
guish whether  we  really  have  peritoneal,  rather  than  pleuritic,  friction- 
sound.  Auscultating  with  the  stethoscope  enables  us  to  localize  the 
sound  more  exactly.  We  must  also  take  into  consideration  the  whole 
picture  of  the  disease. 

Examination  of  the  Pancreas,  Omentum,  Retro-peritoneal 

Glands. 

The  pancreas  is  accessible  for  examination,  and  even  to  palpation, 
if  it  is  the  seat  of  new  formation,  as  of  carcinoma,  especially  of  the 
caput  pancreatis,  and  hence  is  larger  and  harder  than  normal :  we 
have  a  roundish  tumor  in  the  right  epigastrium  which  does  not  move 
during  respiration,  about  midway  between  the  point  of  the  xiphoid 
cartilage  and  the  umbilicus,  hence,  directly  under  the  border  of  the 
liver ;  or  a  somewhat  longer  tumor  across  the  epigastrium.  Unless  there 
are  characteristic  associated  symptoms  (compression  of  the  ductus 
choledochus  and  pancreaticus,  biliary  engorgement,  and  change  in  the 
character  of  the  stools),  the  diagnosis  of  tumor  of  the  pancreas  can 
scarcely  be  made  from  such  a  tumor,  which  may  also  belong  to  the 
omentum,  but  especially  to  the  retro-peritoneal  glands. 

The  omentum,  also,  is  only  perceptible  when  it  is  thickened  by 
inflammation  or  new  formations,  or  by  both.  It  frequently  shrinks 
up  to  a  transverse  band  which  lies  close  above  the  umbilicus,  as  in 
tuberculosis,  but  doubtless  also  in  "simple"  chronic  peritonitis.  Car- 
cinomatous knots  in  the  omentum  are  best  to  be  distinguished  from 
similar  deposits  in  the  anterior  wall  of  the  stomach,  by  examining  the 
latter,  both  when  empty,  and  full,  or  inflated.  Sometimes  it  is  very  . 
difficult  to  distinguish  them  from  carcinoma  of  the  liver,  especially  if 
the  omentum,  from  adhesion  with  the  liver,  moves  with  each  respira- 
tion.    Echinococcus  of  the  omentum  is  quite  rare. 

Enlargement  of   the  retro-peritoneal    glands  generally  occurs  in 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  34I 

secondary  carcinoma  as  firm,  immovable  bunches,  which  are  located 
in  the  cavity  of  the  abdomen,  about  on  the  level  with  the  umbilicus  ; 
but  sometimes  they  reach  even  deeper.  They  may  compress  the  side 
of  the  inferior  vena  cava  or  the  iliac  vein.  This  may  easily  be  con- 
founded with  aneurism  of  the  aorta,  especially  if  it  is  a  round  tumor 
and  propagates  pulsations,  and  it  may  also  even  communicate  a  hum- 
ming murmur  of  stenosis  from  the  aorta. 

We  must  again  call  attention  to  the  importance  of  always  emptying 
the  intestines  and  bladder  in  all  cases  of  this  character  where  the 
diagnosis  is  difficult. 

This  is  not  the  place  to  explain  the  differential  diagnosis  of  a  large 
number  of  other  affections  of  the  abdomen,  especially  tumors  of  the 
uterus,  ovaries  ;  also,  pregnancy.  (We  refer  for  these  to  works  upon 
Gynaecology  and  Obstetrics.) 

Examination  of  the  Contents  of  the  Stomach. 

In  general  we  may  obtain  the  contents  of  the  stomach  for  examina- 
tion in  two  ways :  when  the  patient  vomits,  or  when,  by  emptying  the 
stomach  by  means  of  an  oesophageal  catheter,  we  remove  a  portion  of 
its  contents.  The  catheter  may  be  introduced  for  therapeutic  purposes, 
or  only  for  the  purposes  of  diagnosis. 

The  latter  way  of  obtaining  some  of  the  contents  of  the  stomach,  it 
is  readily  seen,  is  the  more  exact  for  making  a  diagnosis,  because 
we  regulate  the  time  for  doing  it  by  the  object  we  have  in  view. 
First,  with  reference  to  the  most  important  problem  in  the  diagnosis 
of  the  contents  of  the  stomach,  namely,  the  examination  of  the  stomach- 
digestion  and  the  secretion  of  gastric  juice,  it  is  only  necessary  to 
empty  the  stomach  to  obtain  the  object  required.  At  the  same  time, 
it  is  to  be  remembered  that,  in  many  cases,  the  examination  of  vomited 
matters  or  the  fluid  employed  in  rinsing  out  the  stomach  (especially 
in  cases  of  poisoning)  is  of  very  great  importance,  and  is,  then,  not  to 
be  overlooked. 

Artificial  emptying  of  the  stomach  or  removal  of  some  of  its  contents 
for  the  purposes  of  diagnosis  is,  as  has  been  said,  the  only  method 
which  enables  us  to  form  a  reliable  opinion  regarding  the  gastric 
secretion  and  the  process  of  digestion,  for  the  reason  just  given,  that 
such  an  opinion  can  usually  only  be  formed  when  the  contents  of  the 


342  SPECIAL  DIAGNOSIS. 

stomach  have  been  obtained  in  a  pure  state  and  at  a  definite  time  after 
partaking  of  a  meal.  Vomiting  can  make  the  artificial  emptying  of 
the  stomach  unnecessary  only  when  it  occurs  at  exactly  the  time 
desired,  and  when  the  material  vomited  does  not  contain  bile  and  not 
too  much  mucus  (see  below). 

Induction  of  emesis  is  contra-indicated  when  there  is  a  tendency  to 
hemorrhage,  and  in  poisoning,  where  we  have  reason  to  think  the 
poisons,  as  acids  and  alkalies,  have  caused  erosion  of  the  oesophagus 
or  stomach.  Sounds,  even  soft  ones,  are  to  be  employed  with  the 
greatest  caution  if  there  has  ever  been  any  hemorrhage  of  the  stomach, 
and  also  when  there  is  any  suspicion  of  an  ulcer  of  the  stomach  or  of 
a  carcinoma  that  is  eating  through  the  walls. 

,  Knowledge  regarding  the  secretion  of  gastric  juice  and  stomach- 
digestion  is  important  really  in  three  directions,  because,  by  means  of 
it,  certain  diseases  may  be  recognized  early,  before  inspection,  palpa- 
tion, etc.,  are  of  any  value,  or  where  these  methods  do  not  in  any  way 
give  any  result.  And  even  where  other  methods  of  examination  have 
led  to  a  positive  conclusion,  the  diagnosis  is  not  only  made  still  more 
definite  by  this  knowledge,  but  likewise  the  effect  of  a  disease  of  the 
stomach  upon  its  functions  is  determined.  Lastly,  there  is  sometimes 
a  flat  contradiction  between  the  severe  complaints  of  the  patient 
regarding  the  stomach  and  a  perfectly  normal  gastric  digestion.  In 
this  case,  the  examination  of  the  contents  of  the  stomach  immediately 
furnishes  an  explanatibn,  as  in  some  forms  of  "nervous"  dyspepsia. 

EXAMINATION    OF    THE    PROCESS    OF    DIGESTION. 

Stomach-digestion  and  its  Disturbances. 

1.  After  partaking  of  a  meal  which  contains  albumen  and  starch 
(fat  does  not  come  under  consideration,  because  it  is  not  digested  by 
the  stomach),  there  first  occurs,  under  the  influence  of  the  ptyalin  of 
the  saliva,  the  amylolytic  period  of  digestion :  the  starch  contained  in 
the  food  taken  gradually  disappears,  and  dextrine  takes  its  place 
(achroo-  and  ery thro- dextrine)  and  there  is  a  slight  amount  of  grape- 
sugar  ;  any  cane-sugar  that  has  been  taken  is  inverted,  that  is,  is  partly 
transformed  into  grape-sugar.  These  processes  go  on  tolerably  rapidly. 
Moreover,  under  the  influence  of  microorganisms  that  excite  fermenta- 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  34.3 

tion,  there  occurs  a  partial  lactic-acid  fermentation  of  the  grape-sugar, 
and  hence  lactic  acid  is  formed  (lactic-acid  fermentation). 

This  amylolytic  period  varies  in  length  according  to  the  size  of  the 
meal ;  on  the  average,  it  lasts  three-quarters  of  an  hour.  As  a  matter 
of  course,  it  is  entirely  absent  if  only  meat  is  eaten ;  then,  also,  there 
is  no  lactic  acid. 

Immediately  after  food  is  taken,  the  mucous  membrane  of  the  stomach 
begins  to  secrete  muriatic  acid  and  pepsin,  and  the  stomach-juice  mixes 
with  the  alkaline  chyme.  But  at  first  the  muriatic  acid  is  in  combi- 
nation, and  we  do  not  have  free  muriatic  acid  in  any  quantity  until,  on 
the  average,  one-half  to  three-quarters  of  an  hour ;  thus  the  amylo- 
lytic period  is  brought  to  a  close,  because  the  diastatic  action  of  the 
saliva  cannot  go  on  in  an  acid  solution.  Instead,  there  begins  the 
peptonizing  action  of  the  secretion  of  the  stomach  upon  the  albuminous 
bodies.  The  lactic  acid  disappears,  and  after  the  first  hour  none,  or 
only  a  trace  of  it,  can  be  detected.  The  stomach  now  contains  an 
increasing  amount  of  free  muriatic  acid,  and  this  reaches  its  maximum, 
0.2  per  cent.,  or  less,  according  to  the  size  and  character  of  the  meal, 
from  two  to  five  hours  after  the  time  it  was  eaten.  From  now  on  there 
appear  peptones  and  their  precursors  (syntonin  and  propeptone). 

Simultaneously  with  the  free  muriatic  acid,  the  [milk-curdling 
ferment]  rennet-ferment  appears,  under  whose  action  the  casein  of 
the  milk  that  has  been  taken  is  coagulated. 

The  pepsin  and  rennet-ferment  are  not  secreted  as  such  by  the 
mucous  membrane  of  the  stomach,  but  are  formed  by  their  zymo- 
gens [Q^firi,  ferment],  propepsin  and  rennet-zymogen.  Both,  under 
the  influence  of  the  muriatic  acid,  become  transformed  into  pepsin 
and  rennet-ferment.  The  lactic  acid,  although  in  very  much  larger 
quantity,  has  this  effect  upon  the  zymogens  also. 

This  second  or  muriatic-acid  period  of  stomach-digestion,  now  shows 
the  very  important  peculiarity  that,  during  its  course,  under  the  influ- 
ence of  the  0.2  per  cent,  of  free  muriatic  acid,  we  have  the  antiseptic 
action  of  the  gastric  juice,  by  which  the  greater  proportion  of  the 
microorganisms  swallowed  with  the  food  and  drink,  particularly  those 
that  excite  fermentation  and  putridity,  as  well  as  certain  pathogenic 
ones,  as  the  cholera  bacillus,  are  destroyed. 

During  the  progress  of  stomach-digestion  the  food  is  mixed  by  peris- 
talsis, and  partly  by  the  aid  of  the  ferments  is  comminuted  and  reduced 


344  SPECIAL  DIAGNOSIS. 

to  a  homogeneous  mass.  A  small  portion  of  the  fluid  resulting  from_ 
digestion  is  absorbed  ;  but  besides,  at  the  pyloric  end  of  the  stomach,  a 
continuous  separation  of  the  solid  and  fluid  portions  is  going  on,  and 
the  latter,  during  the  whole  period  of  digestion,  passes  little  by  little 
into  the  duodenum. 

2.  About  six  hours  after  a  mixed  meal  of  moderate  quantity  (much 
sooner  after  a  smaller  one),  the  stomach  has  become  entirely  empty, 
or  at  most  contains  only  small  particles  of  food.  In  the  interval 
until  the  next  meal,  in  the  great  majority  of  healthy  persons,  it  appears 
that  the  stomach  contains  a  very  scant  amount  of  clear  fluid,  with  a 
neutral  reaction,  but  no  muriatic  acid  or  pepsin. 

The  stomach-digestion  of  nurslings  has  as  yet  been  very  little 
studied.  According  to  Leo,  the  fasting  stomach  of  a  nursling  almost 
always  contains  free  muriatic  acid,  while  during  digestion  free  muriatic 
acid  cannot  at  all,  or  only  after  an  hour,  be  demonstrated ;  this  is 
not  because  there  is  none  secreted,  but  because  it  is  neutralized  by  the 
milk.  Leo  always  found  rennet-ferment,  excepting  in  one  case  where 
there  was  rennet- zymogen.  After  half  an  hour,  the  greater  portion  of 
the  milk  has  passed  into  the  intestine,  and  in  one,  or  at  most  two  hours, 
the  stomach  is  empty.  Leo  also  thinks  that  the  peptonizing  of  the 
milk  in  the  stomach  is  a  subordinate  process.  He  regards  the  stomach 
as  really  a  milk-reservoir,  and  perhaps  as  oifering  a  barrier  to  patho- 
genic micro5rganisms. 

3.  The  chief  points  in  regard  to  the  eff"ect  of  pathological  disturb- 
ances of  the  gastric  secretion,  of  the  motions  of  the  stomach  upon 
digestion,  and  the  sterilization  of  the  food  and  its  further  transporta- 
tion into  the  intestine,  are  as  follows : 

Diminished  secretion  of  muriatic  acid  (subacidity,  hypacidity) 
interferes  with  the  digestion  of  albumen  and  the  power  of  the 
stomach  to  prevent  decomposition  and  fermentation. 

When  the  muriatic  acid  is  increased  (superacidity,  hyperacidity), 
free  acid  is  present  earlier,  and  thus  there  is  interference  with  the 
digestion  of  the  starches,  because  this  only  goes  on  while  the  contents 
of  the  stomach  have  an  alkaline  reaction ;  likewise,  the  albuminous 
bodies  are  either  normally,  or  more  rapidly,  peptonized,  but  in  some 
cases  it  is  remarkable  that  they  are  more  slowly  peptonized. 

Diminution  of  the  muriatic  acid  generally  appears  to  go  parallel 
•with  a  diminution  of  the  pepsin.     On  the  other  hand,  this  parallelism 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  345 

is  generally  not  present  when  there  is  superacidity ;  with  increase  of 
the  muriatic  acid,  there  even  appears  to  be  an  absence  of  pepsin.  At 
least,  this  latter  condition  alone  explains  those  cases  where  the  pepto- 
nization of  the  albuminous  bodies  is  prolonged,  although  the  free  acid 
is  increased. 

Hence,  with  subacidity  (inacidity)  not  only  are  the  albuminous 
bodies  imperfectly  digested,  but  under  the  influence  of  the  unrestrained 
development  of  microorganisms  there  occurs  an  abnormal  decomposi- 
tion, and  particularly  of  fermentation  with  formation  of  lactic  acid  in 
excess  of  the  normal  time  and  amount,  as  well  as  of  other  organic 
acids.  This  abnormal  chemical  activity  in  turn  produces  a  paralvsis 
of  peristalsis  and  muscular  tone.  The  removal  of  the  food  stops  for 
this  reason,  and  probably  also  because  the  pylorus  does  not  readily 
allow  material  to  pass  into  the  duodenum  which  is  in  an  abnormal 
chemical,  and  in  part  physical,  condition.  The  food  remains  too  long 
in  the  stomach,  and  hence  the  stomach-digestion  is  prolonged.  Lastly, 
if  the  condition  persists,  there  is  ectasia  or  dilatation  of  the  stomach. 
It  is  to  be  remarked  that  by  the  word  dilatation  alone  is  always  meant 
permanent  dilatation,  in  contradistinction  from  temporary  dilatation, 
which  occurs  after  every  meal. 

Quite  similar  in  its  final  results  is  the  efiect  of  a  hindraiice  to  the 
emptying  of  the  stomach,  as  is  particularly  frequent  with  pyloric 
stenosis ;  only  here  the  disturbance  is  on  the  whole  much  more  marked. 
In  stenosis  of  the  pylorus,  the  difficulty  in  expelling  the  food  is  at  first 
overcome  by  an  hypertrophy  of  the  muscular  coats  of  the  stomach ; 
but  gradually  there  becomes  manifest  a  disproportion  between  the 
strength  of  the  stomach  and  the  narrowed  passage.  Part  of  the  con- 
tents of  the  stomach  remain  behind  at  the  time  of  the  next  meal,  and 
so  the  stomach  becomes  more  and  more  dilated.  There  is  an  accumu- 
lation of  material  (peptones,  albuminates,  muriatic  and  phosphoric 
acid  salts) ;  and  the  muriatic  acid,  though  free,  is  yet  so  interfered 
with  that  it  no  longer  exerts  its  peptonizing  and  antifermentative 
action.  There  is  no  further  digestion,  but  in  place  of  it  the  food 
accumulated  in  the  stomach  takes  on  fermentation,  with  formation  of  a 
great  amount  of  lactic  acid,  butyric  acid,  acetic  acid,  and  alcohol. 

Through  this  abnormal  chemical  action,  peristalsis  and  the  muscular 
tone  are  still  more  weakened:  there  results  a  true  eir cuius  vitiosus  of 
the  motor  and  chemical  phenomena. 


346  SPECIAL  DIAGNOSIS. 

4.  The  chief  points  in  the  symptomatology  of  a  distended  stomach 
are  the  following : 

Subacidity  or  inacidity  may  be  recognized  by  the  diminished  per- 
centage of  muriatic  acid  or  its  absence.  Further,  there  are  signs  of 
abnormal  fermentation,  of  which  the  most  important  is  the  unusual 
duration  and  amount  of  lactic  acid.  Digestion  is  usually  prolonged: 
the  stomach  is  not  empty  after  seven  hours ;  it  still  contains  un- 
changed particles  of  meat,  discernible  microscopically  or  even  macro- 
scopically.  If  we  institute  experimental  digestion  with  the  gastric 
juice  in  an  incubator  (see  below),  we  find  that  it  is  diminished,  or  that 
it  has  lost  its  power  to  digest  albumen. 

Superacidity  during  digestion  shows  an  increased  amount  of  free 
muriatic  acid :  usually  the  free  acid  makes  its  appearance  too  early ; 
the  amylolytic  period  is  thus  shortened,  and  there  is  unchanged 
starch  (microscopically  and  chemically  demonstrable).  Albuminous 
digestion  in  the  incubator  may  be  quickened. 

Increased  difficulty  in  conveying  the  food  from  the  stomach  (especi- 
ally when  due  to  stenosis  of  the  pylorus)  is  connected  with  diminution 
or  absence  of  free  muriatic  acid.  Thus,  the  secretion  of  acid  may  be 
normal  or  even  increased;  but  the  muriatic  acid  is  loosely  connected 
with  the  bulky  remaining  albuminates,  peptones,  and  salts,  and  hence 
is  without  chemical  or  antiseptic  action  on  the  one  hand,  and,  on  the 
other,  its  presence  is  "  concealed,"  or  cannot  be  established  by  the  ordi- 
nary reactions.  The  great  amount  of  lactic  acids  (butyric  and  acetic 
acids)  is  shown  by  the  amount  of  fermentation.  The  diminished 
digestion  of  all  kinds  of  food  shows  this  plainly.  In  the  incubator 
the  albumen  is  not  digested. 

5.  A  peculiar  anomaly  as  respects  the  gastric  secretion  consists  in 
the  fact  that  even  Avhen  the  stomach  is  empty,  muriatic  acid,  pepsin, 
and  rennet-ferment,  or  propepsin  and  rennet-zymogen,  are  secreted 
(supersecretion,  hypersecretion).  A  very  considerable  amount  of  this 
gastric  secretion  may  be  accumulated  in  the  stomach ;  and  this  is 
still  more  increased  by  the  fact  that,  generally,  the  presence  of  an  acid 
fluid  in  the  stomach  stimulates  the  secretion  of  saliva.  The  saliva 
swallowed  is  not,  however,  sufficient  to  neutralize  the  acid  fluid. 

Schreiber  has  recently  found  that,  even  in  persons  who  are  in  per- 
fect health,  there  is  a  small  quantity  of  acid  gastric  secretion  in  the 
fasting  stomach.     This  is  in  direct  contradiction  of  the  statements  of 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  347 

former  authors.     We  will  again  enter  (p.  355)  upon  the  question  of 
the  gastric  secretion  in  the  fasting  stomach. 

Mode  of  Procedure  in  Examining  the  Stomach- Digestion. 

The  action  of  the  stomach  is  divided  into  the  chemical  effect  of  its 
secretion  and  the  assistance  furnished  by  mechanically  mixing  the 
food  and  reducing  it  to  small  particles;  the  passing-on  of  the  digested 
or  sterilized  material,  and  the  absorption  of  a  portion  of  it.  Com- 
pared with  that  which  is  passed  along,  the  amount  absorbed  seems  to 
be  small.  These  processes  imply,  as  has  been  shown  above,  a  certain 
length  of  time,  which,  in  health  and  when  a  meal  of  moderate  size  is 
eaten,  takes  place  within  tolerably  definite  limits. 

Thus,  the  examination  of  the  action  of  the  stomach  is  connected 
with  the  determination  of  the'  duration  of  digestion,  the  examination 
of  the  chemical  action  during  digestion,  lastly,  the  relation  of  the 
onward  movement  and  absorption. 

I.  Duration  of  digestion.  Since  the  duration  of  digestion  very 
much  depends  upon  the  kind  and  size  of  the  meal,  in  making  the 
examination,  it  is  indispensably  necessary  to  arrange  similar  conditions 
artificially.  This  requirement  will  be  met  by  Leube's  experimental 
meal,  consisting  of  a  plate  of  water-gruel,  an  ordinary  piece  of  beef- 
steak, and  white  bread.  After  partaking  of  this  meal,  the  patient  takes 
nothing  until  seven  hours  from  the  time  it  was  eaten,  when  the 
stomach  is  to  be  emptied  by  means  of  an  oesophageal  catheter. 
When  the  digestion  is  normal,  the  stomach  after  this  space  of  time 
is  empty,  or  contains  only  a  few  particles  of  the  remains  of  the  food. 

The  stomach  is  emptied  or  washed  out  by  means  of  an  oesophageal 
catheter  and  a  siphon,  or  exceptionally  by  employing  a  stomach- 
pump.  We  employ  a  soft  N^laton's  oesophageal  catheter  of  at  least 
0.6  cm.  internal  diameter,  to  which  we  attach  a  piece  of  rubber 
tubing,  1  m.  to  1.20  m.  in  length,  with  a  short  piece  of  glass  tubing 
inserted  along  its  course ;  on  the  other  end  of  the  tubing  is  a  glass 
funnel.  The  catheter  is  introduced  without  a  guide ;  in  short,  like 
any  other  oesophageal  sound  (see  p.  293).  After  it  has  been  used 
several  times,  the  patient  learns  to  introduce  it  himself,  which  he  does 
by  a  sort  of  swallowing  motion.  Care  must  be  taken  lest  the  sound 
goes  clear  down,  as  has  more  than  once  happened. 


348  SPECIAL  DIAGNOSIS. 

If  the  stomach  is  quite  full,  then  immediately  after  the  catheter  is 
introduced  its  contents  well  up  through  it,  even  if  the  rubber  tube 
and  funnel  have  not  been  attached.  If  the  stomach  is  only  moder- 
ately full,  then  it  is  often  simply  necessary  to  press  the  patient  in 
order  to  bring  up  the  contents  of  the  stomach  through  the  catheter. 
If,  in  this  way,  we  do  not  receive  anything,  then,  if  there  is  no  reason 
to  suspect  an  ulcer  or  a  carcinoma  that  will  bleed  easily,  we  may 
carefully  aspirate  with  a  stomach-pump.  If,  even  then,  we  do  not 
get  anything,  we  must  wash  out  the  stomach  with  a  small,  but 
measured,  amount  of  water,  so  as  to  see  whether  there  are  still  some 
remaining  particles  of  food.  For  this  purpose  we  fill  the  tube  and  a 
part  of  the  funnel  with  lukewarm  water,  before  connecting  it  with  the 
catheter,  and  then  we  pour  more  water  into  the  funnel,  hold  it  high 
and  allow  the  water  to  run  into  the  stomach.  Next,  before  it  is  quite 
empty,  we  lower  the  funnel  quickly  into  a  vessel  standing  ready  upon 
the  floor :  the  tubing  and  funnel  act  as  a  siphon,  and  suck  out  the 
contents  of  the  stomach.  By  filling  and  emptying  it  several  times,  the 
stomach  will  generally  be  completely  emptied. 

If,  in  this  way,  we  cannot  obtain  sufficient  siphon-action,  we  can 
increase  the  suction  power  of  the  apparatus  by  placing  the  funnel  in 
a  vessel  of  water,  extending  the  rubber  tube,  and  then  lifting  the 
funnel  a  little  in  the  water. 

If  the  rinsings  of  the  stomach  after  seven  hours  contain  at  most 
only  a  few  remnants  of  food,  in  most  cases  the  digestion  is  normal. 
At  any  rate,  if  it  is  tolerably  certain  that  there  is  diminution  of  gas- 
tric juice,  we  can  almost  certainly  conclude  that  the  power  of  the 
stomach  to  empty  itself  is  unimpaired.  But  it  is  possible  that  there 
is  superacidity,  and,  as  a  matter  of  course,  supersecretion.  If  this 
is  the  case,  we  repeat  the  experiment,  except  that  the  catheter  is 
introduced  one  or  two  hours  sooner.  In  this  way  we  determine  the 
duration  of  digestion. 

If,  after  seven  hours,  the  stomach  still  contains  considerable  por- 
tions of  food,  then  digestion  is  prolonged  :  subacidity,  or  there  is  inter- 
ference with  the  physiological  emptying  of  the  stomach :  stenosis  of 
the  pylorus,  diminished  peristalsis,  or  dilatation.  Digestion  of  a  simple 
meal  (see  above)  lasting  longer  than  seven  hours  is,  in  health,  only 
observed  in  menstruating  women. 

II.  The  chemistry  of  digestion.  We  may  again  employ  Leube's 
experimental  meal  for  investigating  the  chemistry  of  digestion.    Some- 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  349 

times  we  may  make  use  of  what  we  obtain  while  determining  the  dura- 
tion of  digestion — that  is,  if  seven  hours  after  the  meal  we  find  the 
stomach  yet  full.  If  it  is  empty,  then  we  repeat  the  experimental 
meal,  and  make  the  trial  five  hours  after  it.  If  we  then  find  it  empty 
(which,  normally,  is  not  seldom  the  case),  we  go  back  to  four  hours.  In 
such  cases,  at  any  rate,  where  there  is  free  muriatic  acid,  we  endeavor 
to  examine  the  contents  of  the  stomach  at  the  height  of  the  muriatic- 
acid  digestion — that  is,  at,  the  time  when  the  muriatic  acid  has  its 
chief  value.  This  is  usually  about  an  hour  before  the  close  of  the 
period  of  gastric  digestion. 

Ewald  has  introduced  an  important  simplification  of  this  examina- 
tion. He  gives  a  test-breakfast,  consisting  of  a  dry  roll  and  luke- 
warm water  or  dilute  tea,  which  are  taken  fasting.  The  period  of 
digestion  is  thus  so  shortened  that  one  hour  after  digestion  has 
reached  its  highest  point. 

In  regard  to  the  dispute  as  to  which  is  preferable,  the  experimental 
meal  or  the  experimental  breakfast,  we  take  the  ground  that  the  latter 
is  decidedly  to  be  preferred  for  settling  the  important  points  we  are 
seeking,  particularly  for  the  practising  physician,  who  is  not  able  to 
control  his  patients,  and  hence  must  choose  the  experiment  lasting 
one  hour  rather  than  the  other,  where  he  is  obliged  to  be  away  from 
his  fasting  patient  from  four  to  six  hours.  But,  on  the  other  hand,  we 
must,  with  others,  emphasize  the  fact  that  the  experimental  breakfast 
makes  too  slight  a  demand  upon  the  stomach  to  permitof  a  nice  judgment 
as  to  what  it  can  do.  Hence,  our  experience  leads  us  to  believe  that  the 
experimental  breakfast  may  mislead  us  in  two  diametrically  opposite 
directions — in  many  cases,  by  the  digestive  power  of  the  stomach  seem- 
ing greater  than  it  is ;  or,  in  other  cases,  that  it  does  not  appear  to  be 
as  strong  as  it  really  is,  because  it  is  too  little  stimulated  (in  certain 
nervous  dyspepsias,  also  in  many  cases  of  chronic  catarrh,  as  alcoholic 
catarrh).  The  greater  "cleanliness"  of  his  experiment,  as  Ewald 
maintains,  cannot  be  recognized  as  regulative ;  after  filtration,  in  all 
cases,  we  obtain  after  the  experimental  meal  a  perfectly  clear  fluid, 
which  responds  very  well  to  the  reactions  presently  to  be  described. 

Jaworski  gives  as  the  experimental  meal  the  albumin  of  two  boiled 
eggs  with  100  gm.  of  water — a  simplification  which  we  do  not  think 
useful  or  necessary.  It  is  an  unnatural  experiment,  as  the  well-known 
instinctive  disgust  for  food  of  pure  albumin  proves. 


350  SPECIAL  DIAGNOSIS. 

The  following  procedure  is  recommended  for  making  the  examina- 
tion : 

1.  We  satisfy  ourselves  whether  there  is  any  bile,  blood,  or  pus  in 
the  contents  of  the  stomach  (see  Vomit).  If  there  is  not,  then  we 
filter  a  portion  for  further  examination. 

2.  We  carefully  examine  the  residuum  upon  the  filtering-paper 
with  the  naked  eye.  If  an  experimental  meal  has  been  given,  then  we 
observe  how  thoroughly  the  masses  of  meat  have  been  macerated,  especi- 
ally whether  the  maceration  is  uniform ;  further,  we  notice  whether 
there  are  any  unchanged  particles  of  bread.  (Regarding  certain  things 
seen  under  the  microscope,  see  Vomit.) 

3.  We  test  the  reaction  of  the  fluid-filtrate  with  litmus  (paper  or 
tincture).  An  acid  reaction  may  be  due  to  muriatic  acid  or  organic 
acids,  or  both. 

4.  Then  follows  the  qualitative  examination  for  free  muriatic  acid 
and  lactic  acid. 

For  testing  for  free  muriatic  acid  we  recommend  the  test  with 
tropaolin-paper.^  W^e  moisten  the  paper  with  a  drop  of  the  filtrate, 
then  place  the  bit  of  paper  in  a  watch-glass  and  heat  it.  If  there  is 
free  HCl,  the  tropaolin-paper  first  becomes  brown,  then,  as  it  dries, 
lilac  color.  Approximately  equivalent  is  the  test  with  a  saturated 
alcoholic  solution  of  00-tropaolin,  which  has  been  mixed  with  a  double 
quantity  of  the  filtrate  in  a  small  porcelain  dish,  distributed  by 
whirling.  After  pouring  ofi"  the  surplus,  it  is  to  be  slowly  heated : 
free  HCl  yields  a  lilac-red  reflection.  Lactic  acid  gives  no  reaction, 
even  when  tolerably  concentrated  (0.6  per  cent.).  It  is  very  distinct 
when  the  solution  of  HCl  is  pure — about  0.05  per  cent.  In  the  pres- 
ence of  albumin,  peptones,  phosphates,  it  is  much  less  distinct. 

Still  more  certain  and  much  more  distinct,  while  its  distinctness  is 
much  less  affected  by  other  substances,  is  the  phloroglucin-vanillin  test. 
The  reagent  consists  of  phloroglucin  2  parts,  vanillin  1  part,  to  absolute 
alcohol  30  parts.  Of  this,  one  or  two  drops  are  placed  in  a  shallow  por- 
celain dish,  with  an  equal  amount  of  the  filtrate,  and  carefully  heated. 
Free  HCl  gives  a  deep  red,  or,  if  the  quantity  is  small^  a  bright 
rosy-red  deposit;  if  there  is  no  HCl,  then  the  deposit  is  brown-red 
or  brown.     It  is  distinct — even  to  0.05  per  thousand.     It  is  very 

1  Filter-paper  soaked  with  a  saturated  solution  of  00-Tropaolin. 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  351 

nearly  absolutel}'^  certain  ;  its  only  drawback  is  that  the  reaction  takes 
place  also  in  the  presence  of  sulphuretted  hydrogen  (hence,  after 
tainted  eggs  have  been  eaten).  This  test  very  much  surpasses  all 
others.     It  is  sufficient  to  employ  this  only. 

Of  the  numerous  other  tests  we  only  mention  :  The  reaction  with 
methyl-violet,  which  is  applied  as  follows :  two  reagent-glasses  are 
half-filled  with  a  transparent  solution  of  methyl-violet,  and  to  this 
some  of  the  filtrate  is  added.  Free  HCl  colors  methyl-violet  blue. 
The  reaction  is  not  very  distinct,  nor  is  it  very  reliable;  it  can  be 
imitated  by  table-salt,  and  it  may  be  concealed  by  albuminate,  pep- 
tone, etc.  There  are  also  to  be  named :  congo-paper,  blue  ultramarine, 
and,  lastly,  resorcin,  recently  recommended  by  Boas  (resorcin  5 
parts,  sugar  3  parts,  dilute  spirit  to  100  parts). 

The  examination  for  lactic  acid  is  conducted  in  the  way  suggested 
by  Uffelmann  :  to  about  100  gm.  of  a  2-per-cent.  solution  of  carbolic 
acid  we  add  one  to  two  drops  of  a  solution  of  chloride  of  iron,  when 
the  mixture  becomes  steel-blue.  To  this  we  add  some  of  the  stomach- 
fluid.  If  lactic  acid  is  present,  the  solution  is  discolored  and 
becomes  yellow  or  yellowish-green ;  on  the  other  hand,  if  there  is 
only  HCl,  the  solution  becomes  clear,  like  water.  Butyric  and 
acetic  acids  give  it  a  more  yellowish-red  color ;  moreover,  they  are 
recognized  by  their  odor,  at  any  rate  after  shaking  up  some  of  the 
stomach-fluid  with  ether  and  evaporating  the  ether.  The  test  is  a 
very  delicate  one,  and  shows  0.01  per  thousand  of  lactic  acid.  Its 
certainty  is  somewhat  detracted  from  by  the  fact  that  lactic-acid  salts 
give  the  same  reaction.  It  is  more  important  that  alcohol,  sugar,  and 
acid  salts  cause  the  solution  of  chloride  of  iron  and  carbolic  acid  to 
assume  a  straw-yellow  color.  For  this  reason,  in  case  there  is  no 
pronounced  greenish-yellow,  but  a  straw-yellow  coloration,  we  must 
employ  a  more  certain  method :  we  simply  agitate  some  of  the  filtrate 
with  ether  in  a  reagent-glass,  pour  off  the  ether,  and  then  evaporate 
the  residue  over  hot  water,  not  a  flame.  We  dissolve  the  deposit  in 
water,  and  apply  Uffelmann's  reaction  by  the  addition  of  a  few  drops 
of  the  reagent  (Ewald). 

5.  The  quantitative  examination  of  the  muriatic  acid  has  a  certain 
value  in  subacidity,  but  still  greater  when  there  is  a  suspicion  of 
superacidity.  Let  it  be  once  more  remarked  that  the  latter  may  be 
the  case  not  only  when  the  duration  of  the  digestion  of  albuminous 


352  SPECIAL  DIAGNOSIS. 

material  is  diminished,  but  also  when  it  is  normal,  or  even  when  its 
duration  is  prolonged.  Two  methods  may  be  employed,  in  both  of 
which  the  supposed  time  of  greatest  amount  of  HCl  is  selected.  Pus, 
blood,  bile,  a  large  amount  of  saliva  must  be  excluded.  Repeated 
examination  is  necessary.  If  the  quantity  of  HCl  exceeds  0.3  per 
cent.,  it  may  certainly  be  regarded  as  pathological.  As  much  as  0.6 
per  cent,  of  free  acid  has  been  found. 

First  method :  The  determination  of  the  total  acidity  is  made  by 
neutralizing  it  with  a  normal  solution  of  soda.  Of  course,  this  will 
be  understood  to  have  value  only  in  case  there  are  no  organic  acids 
present,  or  not  an  appreciable  amount  of  them.  It  is  treated  with  a 
1  to  10  normal  solution  of  soda  and  litmus  or  phenol-phtallein  ;  1 
c.c.  of  the  1  to  10  soda  solution  neutralizes  0.0365  HCl. 

Second  method :  As  suggested  by  Giinzburg,  we  can  employ  the 
phloroglucin- vanillin  reaction  for  an  approximative  quantitative  de- 
termination of  HCl,  by  remembering  that  the  reaction  still  positively 
takes  place  in  the  presence  of  0.05  per  thousand  of  HCl.  Hence  we 
have  to  dilute  the  stomach-fluid  with  a  definite  quantity  of  distilled 
water  so  long  as  the  reaction  is  produced  sufficiently  to  be  recognized. 
Since  Giinzburg's  reaction  is  not  disturbed  by  lactic  acid,  the  simul- 
taneous presence  of  lactic  acid  does  not  interfere  with  this  method. 
It  is  still  very  desirable  that  there  should  be  an  exact  revisional  proof 
of  this  method. 

6.  Examining  the  digestion  in  an  incubator.  The  examination  of 
the  digestive  power  of  the  gastric  juice  is  of  especial  value  for  demon- 
strating pepsin.  At  any  rate,  experience  shows  that  when  there  is 
free  muriatic  acid,  pepsin  is  usually  present ;  on  the  other  hand,  when 
muriatic  acid  is  absent,  no  pepsin  is  present,  for  the  reason  that  the 
mucous  membrane  of  the  stomach  does  not  secrete  pepsin  itself,  but 
secretes  its  zymogen,  propepsin,  and  because  muriatic  acid  has  the 
exclusive,  or  at  least  the  chief,  power  to  form  pepsin  out  of  propepsin. 
For  these  reasons,  it  may  suffice,  in  most  cases,  to  examine  for  muri- 
atic acid  alone.  But  the  thorough  examination  is  of  the  greatest 
value  for  arriving  at  a  complete  judgment. 

We  test  the  digestive  power  of  the  gastric  juice  upon  a  piece  of  the 
white  of  a  hard-boiled  egg.  A  piece  about  a  centimetre  square  and  a 
millimetre  thick  placed  in  a  reagent-glass  full  of  normal  stomach-fluid 
should  be  dissolved  in  about  an  hour.     If  the  solution  is  delayed,  or 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  353 

does  not  take  place  at  all,  it  proves  that  there  is  a  deficiency  in  the 
normal  amount  of  pepsin  only  when  we  are  able  to  determine  that 
there  is  also  a  deficiency  in  muriatic  acid.  For  this  reason,  \t  is  best 
to  conduct  the  examination  simultaneously  in  two  reagent  glasses,  to 
one  of  which  a  few  drops  of  HCl  have  been  added. 

The  coagulating  eff"ect  of  the  gastric  juice — that  is  to  say,  of  the 
rennet-ferment — upon  the  casein  of  milk  is  proved  by  the  fact  that,  at 
the  temperature  of  the  body,  neutralized  stomach-filtrate  with  neutral 
(or  amphoteric)  milk  is  coagulated  ;  in  fifteen  to  thirty  minutes,  if  the 
rennet-ferment  is  present,  there  is  coagulation  of  the  casein.  This 
test,  it  seems,  can  generally  be  omitted  if  it  concerns  nurslings,  in 
whom  it  is  of  special  interest :  for  it  has  been  shown  that  when  free 
HCl  and  pepsin  are  present,  the  rennet-ferment  is  never  absent; 
even  in  most  cases  of  absence  of  both  the  others,  rennet-ferment 
indeed  seems  not  to  be  met  with,  but  rennet-zymogen,  which  requires 
muriatic  acid  in  order  to  transform  it  into  rennet-ferment.  In  order 
to  prove  the  presence  of  rennet-zymogen  in  gastric  juice  which  is 
deficient  in  HCl  and  rennet-ferment,  we  supply  the  deficiency  by 
adding  HCl  and  then  allow  it  to  stand  in  an  incubator  for  two 
hours,  after  which  we  apply  the  test  for  the  ferment  mentioned  above. 
In  atrophy  of  the  mucous  membrane  of  the  stomach,  there  is  entire 
absence  of  rennet-zymogen,  as  well  as  of  HCl  and  pepsin. 

Of  the  somewhat  difficult  methods  of  examining  the  products  of 
digestion  we  can  here  mention  the  two  following :  1.  The  transforma- 
tion of  the  starches  into  erythro-  and  achro5-dextrin  can  be  quali- 
tatively followed  by  means  of  dilute  Lugol's  solution  (iod.  1  part, 
iodide  of  potash  2  parts,  aq.  dest.  200  parts);  it  colors  starch  blue; 
erythro-dextrin,  purple-red;  achro5- dextrin  remains  colorless  or  be- 
comes yellow.  A  mixture  of  starch  and  dextrin  with  the  first  drops 
of  the  iodine  solution  becomes  colorless,  but  upon  further  addition  it 
becomes  red  and  then  blue. 

2.  Peptone  and  propeptone  in  alkaline  solution,  upon  the  addition 
of  a  solution  of  sulphate  of  copper,  give  a  beautiful  purple  color ; 
albumin  makes  it  a  blue- violet ;  hence,  on  account  of  this  similarity 
of  colors,  it  is  often  extremely  difficult  to  distinguish  albumin  from 
peptone,  particularly  if  the  stomach-fluid  is  turbid. 

III.  The  effijrt  has  been  made  in  various  ways  to  ascertain  what 
part  the  movements  of  the  stomach  play  in  digestion.     No  method 

23 


354  SPECIAL  DIAGNOSIS. 

that  has  thus  far  been  devised  meets  the  requirement ;  hence,  we  only 
mention  them  very  briefly. 

The  peculiarity  of  salol  that  it  splits  up  into  salicylic  acid  and 
phenol  only  in  the  intestine,  whereupon  the  appearance  of  salicylic 
acid  in  the  urine  is  easily  proved,  has  been  employed  by  Ewald  to 
determine  the  rapidity  of  the  passage  of  food  from  the  stomach  into 
the  intestine.  Salicylic  acid  is  recognized  in  the  urine  after  the  addi- 
tion of  chloride  of  iron  by  the  violet  reaction  in  the  urine.  In  order 
to  recognize  the  first  traces,  we  must  make  the  test  upon  an  ethereal 
extract  [of  the  urine.  (Compare  what  is  said  later  regarding  the 
Urine  after  the  Administration  of  Medicines. y\.  Ewald  found  that  in 
health  the  first  positive  reaction  took  place  one- half  to  one  hour  after 
it  had  been  taken ;  when  the  process  of  transportation  from  the 
stomach  had  been  interrupted,  it  was  later.  However,  the  results  of 
this  procedure  seem  to  be  quite  variable. 

The  same  thing  must  be  said  of  the  use  of  pills  of  iodide  of  potash 
coated  with  keratin,  which  very  evidently  are  preferable,  because  we 
do  not  need  to  employ  the  urine  in  proving  the  absorption  of  the 
iodide,  but  we  can  make  use  of  the  saliva.  But  Stintzing  has  found 
that  these  pills  are  sometimes  dissolved  in  the  stomach. 

Finally,  Klemperer  has  attempted  a  method,  which,  from  a  purely 
technical  standpoint,  is  very  exact,  but  is  decidedly  impracticable. 
He  introduces  into  the  empty  stomach  100  grammes  of  olive  oil,  and, 
after  a  certain  interval,  washes  the  stomach  out.  From  healthy 
stomachs  he  found  that,  in  two  hours,  70  to  80  grammes  of  the  oil  had 
been  discharged  into  the  intestine,  while  in  cases  of  catarrh  of  the 
stomach  about  half,  and  in  one  case  of  atrophy  a  quarter,  of  that 
amount  had  in  the  same  time  disappeared  from  the  stomach.  This 
method  is  less  objectionable,  because  the  oil  is  sometimes  not  borne  in 
the  patient's  stomach — it  may  even  be  rejected.  But  it  is  much  more 
so  because  it  does  not  sufiiciently  irritate  the  stomach. 

Lastly,  the  absorptive  power  of  the  stomach  has  been  frequently  the 
object  of  examination. 

Penzoldt  gives  0.2  iodide  of  potassium  in  gelatin  capsules,  and  then 
at  once  tests  the  saliva  to  see  whether  the  capsule  was  close  and  free 
from  iodide  of  potassium  upon  its  outer  surface.  For  this  purpose  we 
have  the  patient,  moment  by  moment,  spit  upon  a  piece  of  filter-paper 
saturated  with  a  solution  of  starch,  upon  which  we  place  a  trace  of 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  355 

fuming  nitric  acid ;  the  appearance  of  the  iodide  in  the  saliva 
Avill  be  recognized  by  the  red  and  blue  coloration  of  the  paper.  In 
health,  the  iodide  will  make  its  appearance,  if  it  has  been  taken 
upon  an  empty  stomach  or  three  hours  after  eating,  in  from  six  and  a 
half  to  eleven  minutes ;  if  directly  after  a  meal  has  been  eaten,  after 
twenty  to  forty-five  minutes.  In  cases  of  dilatation,  if  taken  upon  a 
fasting  stomach,  its  earliest  appearance  is  after  fifteen  to  thirty 
minutes.  It  also  seems  to,  be  delayed  in  carcinoma,  chronic  catarrh, 
and  in  fevers. 

The  question  is,  whether  we  can  draw  a  conclusion  as  to  the 
absorption  of  the  products  of  digestion  from  the  behavior  of  the 
iodide. 

The  examination  of  the  fasting  stomach  has  for  its  object  the 
determination  of  the  behavior  of  the  gastric  secretion  after  the  com- 
pletion of  stomach-digestion.  Hence,  it  is  conducted  with  reference 
to  the  diagnosis  of  a  possible  hypersecretion. 

Method.  Recent  investigations  upon  this  subject  show  that  it  is 
very  important  to  avoid  making  use  of  the  secretion  of  the  stomach 
which  results  from  any  mechanical  irritation.  Hence,  we  must  be 
very  cautious  and  proceed  very  rapidly.  We  recommend  a  Nelaton's 
sound,  without  an  eye,  but,  instead,  a  number  of  fine  openings  at  the 
end,  which  is  to  be  introduced  into  the  stomach  some  hours  after  we  have 
washed  it  out  in  order  to  make  sure  that  it  was  empty.  Or,  still  better, 
we  first  determine  the  duration  of  digestion,  then  we  allow  the  stomach 
to  be  quiet  after  the  expiration  of  the  last  meal.  Then  a  stomach- 
pump  is  quickly  introduced  ;  aspirate,  withdraw  the  sound,  and  empty 
it  into  a  vessel.  Next  we  examine  the  fluid  thus  obtained  as  to  its 
reaction,  and,  if  acid,  for  muriatic  acid ;  further,  as  to  its  digesting 
qualities.  For  passing  judgment  upon  the  results  of  this  procedure 
and  its  diagnostic  significance,  see  the  following  pages. 

Finally,  on  account  of  its  historical  interest,  we  mention  here  the 
method  given  by  Leube,  but  superseded  by  his  experimental  digestion. 
He  introduced  ice-water  into  the  empty  stomach  and  then  aspirated  it, 
in  order  to  obtain  for  examination  the  gastric  secretion  pure — that  is, 
diluted  with  water. 

Results  of  the  examination  of  stomach- digestion :  their  value. 
1.  If  the  examination  of  the  duration  of  digestion  shows  that  it  is  not 
prolonged,  then,  as  a  rule,  the  process  of  digestion  is  normal ;  but 


356  SPECIAL  DIAGNOSIS. 

the  period  of  digestion  may  be  shortened,  and  this  sometimes  is  the 
case  when  there  is  superacidity.  If  the  period  of  digestion  is  pro- 
longed, this  must  be  further  investigated. 

2.  Free  muriatic  acid,  which  belongs  to  the  time  when  normal 
digestion  is  at  its  height,  may  be  completely  wanting  (inacidity, 
anacidity).  This  almost  uniformly  occurs  when  there  is  complete 
destruction  (corrosion)  of  the  mucous  membrane  of  the  stomach,  when 
it  is  atrophied,  or  has  undergone  amyloid  degeneration.  Further, 
inacidity  is  almost  always  present  in  carcinoma  ventriculi  with  dilata- 
tion, more  rarely,  although  also  yery  frequently,  in  all  other  kinds  of 
dilatation.  Of  these  we  must  mention  especially  that  which  occurs 
with  chronic  gastric  catarrh.  The  dilatation  produced  by  the  scar  of 
an  ulcer  (at  the  pylorus),  or  accompanying  an  ulcer,  is  associated  with 
diminution  or  absence  of  free  HCl.  Subacidity,  or  even  inacidity,  is 
further  observed  in  severe  anaemia  of  all  kinds  and  with  fever,  and, 
lastly,  in  certain  cases  of  nervous  dyspepsia. 

Accompanying  this  condition  is  the  more  or  less  markedly  increased 
formation  of  lactic  acids  (butyric,  acetic  acids,  alcohol) — a  sign  of 
abnormal  fermentation.  In  very  severe  cases  it  may  result  in  fetid 
decomposition  of  the  contents  of  the  stomach.  Moreover,  for  an 
unusual  length  of  time  or  continuously,  there  may  be  undigested 
masses  or  fine  particles  of  meat. 

For  reasons  that  are  readily  understood,  the  behavior  of  the  stomach 
in  cases  of  phthisis  has  been  very  much  studied ;  the  results  vary 
in  a  very  remarkable  degree.  The  general  conclusion  from  these 
examinations  (Liebermeister,  Hildebrand,  Brieger)  seems  to  be  that 
in  cases  of  severe  phthisis  with  continued  fever,  very  often  no  free  HCl, 
sometimes  even  no  rennet-zymogen,  is  found,  but  that  free  muriatic  acid 
is  also  sometimes  wanting  in  remittent  fever.  At  any  rate,  the  ex- 
amination of  the  stomach-digestion  in  phthisis  for  prognostic  and 
therapeutic  reasons  is  to  be  recommended  in  every  single  case. 

3.  Increased  amount  of  HCl  at  the  height  of  digestion,  shortening 
of  the  time  (normal  maximum  of  one  hour)  during  which  lactic  acid 
is  present,  are  signs  of  superacidity.  Thus  the  period  of  digestion  is 
shortened,  or  normal,  or  sometimes  even  prolonged.  As  evidence  of 
disturbed  amylolysis,  we  have  unchanged  starch  during  the  whole  period 
of  digestion. 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  357 

Superacidity  is  present  in  the  majority  of  cases  of  ulcer,  also  in 
certain  nervous  dyspepsias  (gastroxynsis,  pyrosis  liydrochlorica),  lastly 
in  acute  and  sometimes  in  chronic  gastric  catarrh.  It  is  also  observed 
in  the  forms  of  insanity  accompanied  with  depression. 

4.  It  has  been  shown  by  recent  investigations  (Schreiber,  and  par- 
ticularly E.  Pick),  regarding  the  significance  of  the  presence  of  acid- 
secretion  of  the  stomach,  that  a  positive  conclusion  from  the  examina- 
tion can  only  be  drawn  AVith  caution,  because  the  irritation  of  the 
sound  seems  to  stimulate  the  stomach  to  pour  out  its  secretion  very 
rapidly.  We  can  only  diagnosticate  supersecretion  (hypersecretion), 
Avhen  by  a  rapid,  careful  procedure  at  least  about  200  c.  c.  of  acid 
gastric  secretion  are  obtained. 

Supersecretion  occurs  in  the  gastric  crisis  of  tabes  and  certain 
neuroses,  as  hysteria  and  nervousness.  It  is  sometimes  also  observ^ed 
with  ulcus  ventriculi,  in  individual  cases  of  carcinoma,  and  in  acute 
and  chronic  catarrh. 

Emptying  the  stomach  for  therapeutic  purposes,  or  Avashing  it  out, 
must  be  undertaken,  in  the  first  place,  in  cases  of  recent  acute  poisoning, 
and  frequently  for  the  purpose  of  diagnosis.  This  is  the  case  in  almost 
all  cases  of  poisoning,  where  the  poison  has  been  swallowed.  But  it 
must  be  remembered  that  in  poisoning  with  substances  that  are  corro- 
sive, as  acids  and  alkalies,  on  account  of  the  danger  of  perforation  of 
the  oesophagus  or  stomach,  the  sound  must  be  used  with  the  greatest 
caution,  or  even  not  at  all.  The  detection  of  the  kind  of  poison  in 
the  contents  of  the  stomach  belongs  to  toxicology.  Some  poisons 
entirely  escape  detection. 

What  has  been  said  above  regarding  the  examination  of  the  con- 
tents of  the  stomach,  explains  the  therapeutic  use  of  washing  out  the 
stomach  when  it  is  diseased,  in  that  it  can  be  employed  for  observing 
the  course  of  the  disturbance  of  digestion  in  diseases  of  the  stomach. 
For  instance,  it  is  evident  from  what  has  been  said  that  it  is  not 
without  value  occasionally  to  institute  a  daily  washing  out  of  the 
stomach,  in  case  it  is  diseased,  to  determine  whether  it  contains  lactic 
acid  many  hours  after  the  last  meal  was  taken.  Also,  frequent  micro- 
scopical examination  of  the  sediment  of  the  rinsings  of  the  stomach 
(in  sarcina  ventriculi,  etc.,  see  Vomit)  is  of  undoubted  value. 


358  SPECIAL  DIAGNOSIS. 

Vomiting,  and  the  Examination  of  what  is  Vomited. 

The  act  of  vomiting  consists  of  one  or  several  strong  forcible  contrac- 
tions which  occur  simultaneously  in  the  oblique  abdominal  muscles  and 
the  diaphragm.  In  this  way  the  stomach  is  compressed,  and,  by  the 
simultaneous  opening  of  the  cardiac  orifice,  its  contents  escape  upward. 
Otherwise  the  stomach  takes  no  active  part  in  expelling  the  food.  From 
the  not  infrequent  presence  of  bile  in  the  last  portions  that  are  vomited 
toward  the  end  of  a  severe  effort  at  vomiting,  it  is  evident  that  the 
pylorus  also  sometimes  does  not  entirely  close. 

In  this  connection  Ave  do  not  include  the  vomiting,  or  rather  the 
expulsion  of  food  from  dilated  parts  of  the  oesophagus  when  there  is 
stenosis  or  diverticula.     (See  Examination  of  the  CEsophagus.) 

Vomiting  may  occur  in  a  great  variety  of  ways,  and  in  diseases  which 
differ  greatly  in  character.  We  suppose  that  the  so-called  vomiting- 
centre  is  situated  in  the  oblongata.  This  may  be  stimulated  from  the 
periphery,  chiefly  through  the  sensory  portion  of  the  vagus,  and  so 
give  rise  to  reflex  vomiting.  Moreover,  it  may  be  stimulated  directly 
or  by  impressions  from  other  portions  of  the  brain  (central  vomiting). 

Children  generally  vomit  easier  than  adults.  There  are  also  indi- 
vidual differences.     Clinically,  we  distinguish : 

1.  Vomiting  occasioned  by  reflex  influences  from  the  stomach.  It 
occurs  in  all  diseases  of  the  stomach,  but  also  in  irritation  of  the  mucous 
membrane  of  the  stomach  by  different  poisons,  certain  emetics,  etc., 
and  also  by  overloading  the  stomach. 

2.  Reflex  vomiting  caused  by  other  abdominal  organs,  as  from  the 
female  sexual  apparatus  in  menstruation,  pregnancy,  diseases  of  the 
sexual  apparatus ;  from  inflammation  of  the  peritoneum  ;  also,  in  renal 
and  biliary  colic,  etc. 

Likewise,  vomiting  may  be  caused  by  irritation  or  tickling  of  the 
fauces.  Probably  here  also  belongs  vomiting  which  occurs  at  the  end 
of  a  severe  fit  of  coughing,  as  in  whooping-cough  and  phthisis. 

3.  Central  vomiting.  It  may  result  from  irritation  of  the  brain  of 
various  kinds :  as  different  evident  diseases  of  the  brain,  especially 
tumors ;  in  the  different  forms  of  meningitis ;  in  neuroses,  particularly 
hysteria ;  and  from  uraemia.  Vomiting  occurs  also  in  the  beginning 
of  certain  acute  infectious  diseases,  as  pneumonia,  scarlet  fever,  small- 
pox, erysipelas,  [remittent  fever]. 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  359 

Vomiting  is  almost  always  accompanied  by  certain  other  phenomena: 
previous  malaise,  often  severe  sweating,  quickening  of  the  pulse; 
exhaustion,  with  the  feeling  of  relief,  but  also  evidences  of  collapse. 
In  diseases  of  the  brain,  it  sometimes  occurs  without  any  preliminary 
indisposition,  even  quite  suddenly  and  unexpectedly. 

As  regards  the  time  when  the  vomiting  begins,  in  diseases  of  the 
stomach,  it  often  (not  always)  follows  eating.  Also  in  peritonitis,  vomit- 
ing is  often  excited  by  th,e  taking  of  food  ;  but  here  also  it  takes  place 
quite  independently  of  this.  The  vomitus  matuiinus  of  drunkards,  as 
a  rule,  regulacly  occurs  early  in  the  morning,  when  the  stomach  is 
empty.  Also  in  certain  nervous  dyspepsias  there  are  apt  to  be  attacks 
of  vomiting  when  the  stomach  is  empty.  When  there  is  severe  vomit- 
ing without  phenomena  of  stomach  or  other  abdominal  disturbances, 
we  must  take  into  consideration  the  other  conditions  named  above — 
acute  infectious  diseases,  disease  of  the  brain,  uraemia,  hysteria — 
according  to  the  circumstances. 

The  frequency  of  vomiting  is  extraordinarily  variable,  and  is  of 
little  moment  in  diagnosis ;  only  that  it  might  be  mentioned  that  in 
very  marked  dilatation  of  the  stomach,  from  pyloric  stenosis,  vomiting 
occurs  remarkably  infrequently,  but  in  most  cases  tolerably  regularly, 
at  intervals  of  several  days  (but  then  very  profusely). 

There  may  be  eructation  in  all  the  conditions  in  which  vomiting 
occurs.  It  is  observed,  especially,  in  slight  and  severe  diseases  of  the 
stomach  of  all  kinds.  The  odor  of  the  eructation  corresponds  to  that 
of  the  contents  of  the  stomach,  as  a  matter  of  course.  (See  under 
Odor  of  the  Vomit.)  In  individual  cases,  combustible  gases  have  been 
observed  (marsh  gas,  and  probably  also  other  gases).  There  occur 
■with  nervous  persons  very  distressing  and  entirely  odorless  eructa- 
tions. 

The  Vomit. 

"When  we  examine  the  vomit,  we  notice  the  quantity,  the  macro- 
scopical  and  microscopical  appearance,  the  odor,  and  the  reaction. 

The  chemical  examination  can  probably  occasionally  enable  us  to 
judge  of  the  character  of  the  stomach-digestion.  This  is  especially 
the  case  in  those  diseases  which  we  cannot  include  in  a  methodical 
investigation,  as,  particularly,  inclination  to  hemorrhage,  etc.  (See 
above.)     Of  course,  we  must  consider  the  relation  of  the  vomiting  to 


360  SPECIAL  DIAGNOSIS. 

the  time  of  the  last  meal,  and  what  this  meal  consisted  of.  The 
points  of  view  are  to  be  taken  from  what  has  been  said  above  regard- 
ing experimental  digestion.  Wnere  there  are  macroscopical  appear- 
ances of  blood  and  coloring  matter  of  bile,  we  must  farther  apply  the 
chemical  tests  for  these  substances. 

The  quantity  vomited.  Here  we  must  consider  the  time  and  fre- 
quency of  the  vomiting,  as  well  as  the  amount  of  food  taken.  When 
there  is  vomiting  from  an  empty  stomach,  there  is  usually  only  a  little 
mucus,  seldom  much  mucus  or  saliva  that  has  been  swallowed  {vomitus 
matutinus  potatorum),  or  more  or  less  pure  gastric  juice  (hypersecre- 
tion). In  acute  infectious  diseases,  diseases  of  the  brain,  uraemia, 
sometimes  scarcely  anything  at  all  is  vomited. 

A  vomiting  which  seems  to  result  from  the  ingestion  of  food,  but 
the  amount  of  which  considerably  exceeds  the  quantity  of  food  and 
drink  last  taken,  is  an  almost  mathematically  sure  proof  of  dilatation 
of  the  stomach.  Here  the  contents  of  the  stomach  may  accumulate 
for  a  number  of  days  and  then  be  thrown  off  en  masse,  to  the  amount 
of  several  litres. 

The  macroscopical  appearance.  This  will  naturally  depend  very 
much  upon  the  food  taken.  It  was  mentioned  above,  when  speaking 
of  the  experiments  with  digestion,  that  under  some  circumstances  we 
can  form  a  conclusion  regarding  digestion  by  the  comminution  of  the 
food.  Some  foods,  as  coffee,  cocoa,  red  wine,  huckleberries,  etc., 
markedly  color  the  vomit,  and  may  sometimes  give  rise  to  mistake,  if 
it  is  superficially  examined,  by  causing  one  to  think  that  there  has 
been  hsematemesis  (the  laity  being  not  infrequently  thus  deceived,  and 
hence  we  must  be  very  careful  in  accepting  the  anamnesis).  When 
preparations  of  iron  have  been  taken,  the  vomit  is  black  ;  but  it  is 
also  sometimes  black  in  acute  lead-poisoning.  Apart  from  the  food, 
we  can,  from  some  prominent  constituents  (when  the  contents  of  the 
stomach  are  abnormal),  make  certain  important  distinctions  in  what  is 
vomited,  just  as  in  the  sputum. 

Watery,  watery-mucous,  mucous  vomit.  The  first  and  the  second 
named  may  ordinarily  have  two  very  different  meanings.  In  both 
cases  we  have  a  somewhat  turbid  fluid,  resembling  saliva  or  fluid 
mucus,  which  is  vomited  from  a  fasting  stomach.  It  has  an  alkaline 
reaction,  and  usually  indicates  chronic  gastric  catarrh.  The  fluid 
consists  of  mucus  from  the  mucous  membrane  of  the  stomach,  and  of 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  3(51 

saliva  that  has  been  swallowed.  In  this  way  the  frequently  men- 
tioned "water-brash"  of  drunkards  {vomitus  matutinus  potatorum) 
especially  manifests  itself  in  the  early  morning,  immediately  after 
rising.  Also  such  vomiting  occurs  (rare)  in  nervous  dyspepsia.  If 
the  fluid  smells  sour,  and  has  an  acid  reaction,  and  if  it  shows  the 
muriatic  acid  reaction  and  power  of  digestion,  then  we  have  gastric 
juice  secreted  by  the  empty  stomach  :  hypersecretion.  This  gastric 
juice  is  often  over-acid — hypersecretion  with  hyperacidity  (over  0.3 
per  cent.).  This  occurs  in  certain  kinds  of  nervous  dyspepsia  (gas- 
troxynsis,  gastroxia ;  also  hysteria ;  tabes),  but  also  in  dyspepsia  fol- 
lowing healed  ulcer,  and  acute  and  chronic  gastric  catarrh.  In  these 
cases  the  quantity  vomited  may  amount  to  several  hundred  grammes. 

A  special  form  of  watery-mucous  vomit  is  peculiar  to  Asiatic 
cholera.  In  this  disease  there  is  often  vomited  a  great  quantity  of 
alkaline,  stale-smelling  fluid,  like  rice-water  (very  like  the  stools  of 
cholera)  (which  see).  The  small  flocks,  like  rice,  are  mucous  flocks. 
It  is  not  possible  to  separate  mucous  from  watery-mucous  vomit. 
Sometimes  a  great  quantity  of  mucus  is  observed  in  chronic  catarrh 
of  the  stomach. 

Vomiting  of  bile.  As  previously  mentioned,  bile  may  be  mixed 
with  every  vomit,  and  this  is  especially  apt  to  be  the  case  in  very 
severe  efforts  at  vomiting,  so  that  toward  the  end  almost  pure  bile  is 
ejected.  The  vomit  looks  yellowish-green  or  green,  and  smells 
decidedly  bilious.  It  exhibits  the  reaction  of  the  coloring  matter  of 
the  bile.     (See  Urine.) 

A  grass-green  bilious  vomit,  occurring  with  tolerable  uniformity, 
with  every  act  of  vomiting  whether  violent  or  not,  is  a  not  unimpor- 
tant peculiarity  of  peritonitis,  and  of  marked  obstruction  of  the 
bowels. 

Bloody  vomit,  vomiting  of  blood  (haematemesis).  Blood  from  the 
nose,  throat,  and  oesophagus  may  become  mixed  with  the  vomit  in  the 
act  of  vomiting.  Small  quantities,  in  streaks,  are  usually  of  no  sig- 
nificance. Large  hemorrhages  from  the  oesophagus,  as  in  varices 
of  the  lower  portion  of  the  oesophagus,  and  in  cirrhosis  of  the  liver, 
usually  after  it  has  run  down  into  the  stomach,  cause  severe  haemate- 
mesis.  Also  blood  from  the  nose,  and  even  from  the  lungs,  may 
reach  the  stomach  and  be  vomited  up  (see  p.  170).  We  must  be 
careful  not  to  confound  such  an  occurrence  with  hemorrhage  of  the 


362  SPECIAL  D/AGNOSIS. 

stomach.  In  doubtful  cases  the  anamnesis  is  of  less  value  than  the 
examination  of  the  stomach,  nose,  and  lungs.  (See  p.  170  for  further 
particulars  regarding  the  distinction  of  hemorrhage  of  the  lungs  from 
that  of  the  stomach.) 

Small  points  of  blood  and  streaks  in  the  vomit,  moreover,  even  if 
they  come  from  the  stomach,  according  to  our  experience,  are  generally 
without  significance  ;  that  they  are  from  the  stomach  is  proved  by  the 
presence,  not  infrequently,  of  bloody  suffusion  of  the  mucous  mem- 
brane of  the  stomach  at  the  autopsy.  Streaks  of  blood  frequently 
recurring,  whose  source  the  autopsy  proves  to  be  the  stomach,  are  not 
at  all  uncommon  in  cirrhosis  of  the  liver. 

Bloody  vomit,  from  hemorrhage  of  the  stomach,  takes  place  in  ulcer 
of  the  stomach,  carcinoma  ventriculi,  portal  engorgement  from  cir- 
rhosis of  the  liver,  closure  of  the  portal  vein  (rarely  in  general  venous 
stasis),  in  severe  lesions  of  the  mucous  membrane  of  the  stomach  by 
corrosive  poisons,  also  in  general  hemorrhagic  diathesis  (see  cutaneous 
hemorrhages),  in  yellow  fever,  melsena  neonatorum  ;  in  the  last-named 
cases  there  usually  occurs  simultaneous  hemorrhage  of  the  bowels. 
Very  decided,  and  sometimes  fatal,  hsematemesis  is  chiefly  peculiar  to 
ulcus  ventriculi  (also  melsena).  In  carcinoma  we  notice  very  fre- 
quently repeated,  but  always  moderate,  hemorrhages.  Moreover,  in 
all  these  conditions  the  vomiting  of  blood  may  be  entirely  wanting, 
either  because  there  is  no  escape  of  blood  into  the  stomach,  or  because 
the  blood  is  nqt  vomited. 

When  we  suspect  hemorrhage  of  the  stomach,  which  is  not  vomited, 
we  are  to  examine  the  stools  (which  see).  Sometimes,  in  ulcer  of  the 
stomach,  the  patient  becomes  suddenly  pale,  may  collapse,  or  may 
even  die  from  a  hemorrhage  of  the  stomach,  Avithout  there  being  any 
vomiting  of  blood.  In  order  to  observe  exactly  an  ulceration  of  the 
stomach,  it  is  particularly  necessary  to  observe  uninterruptedly  the 
stools. 

Pure  blood  is  seldom  vomited,  unless  there  is  a  great  quantity  of  it, 
or  it  is  vomited  directly  after  or  during  the  hemorrhage.  Moreover, 
it  is  never  of  so  clear  an  arterial  color  as  in  hemorrhage  of  the  lungs. 
The  blood  is  almost  always  more  or  less  changed  by  the  gastric  juice : 
it  is  very  dark,  black -brown,  and  has  an  acid  reaction.  If  it  has  been 
in  the  stomach  for  some  time,  as  is  quite  often  the  case  in  carcinoma 
with  dilatation,  because  the  hemorrhages  are  usually  small  and  there 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS  ggg 

are  long  pauses  between  the  hemorrhages,  under  the  influence  of  the 
acids,  by  the  breaking-up  of  the  red  corpuscles  and  the  haemoglobin, 
and  the  appearance  of  hsematin,  it  becomes  coffee-brown  and  also  of 
the  consistence  of  coffee-grounds.  Then,  in  case  it  is  abundant,  it  is 
easy,  with  some  experience,  to  recognize  it ;  yet  it  is  easy  to  confound 
it  with  other  substances,  as  coffee,  cocoa,  etc.  (See  above.)  For  this 
reason,  and  because  here  the  microscope  is  deceptive,  it  is  prefer- 
able, in  this  case,  always^  to  make  a  special  test  of  the  blood. 

Testing  the  blood:  1.  Very  correctly,  the  haemin  test  is  generally 
employed,  because  it  is  certain  and  distinct.  The  following  is  the  best 
way  to  make  it :  Some  of  the  coffee-grounds  material  is  filtered ;  a 

Fig.  92. 


o    \^ 


Crystals  of  hsemin.     Zelss's  apochromatic  lens  No.  8,  eye-piece  No.  8,  camera  lucida. 
Magnified  about  300  diameters. 

little  of  this  is  to  be  evaporated  in  a  watch-glass.  Scrape  off  some  of 
the  dried  material,  mix  it  with  a  trace  of  finely-pulverized  salt,  place 
the  dried  mixture  upon  an  object-glass,  cover  it  with  a  glass  cover, 
and  allow  one  or  two  drops  of  glacial  acetic  acid  to  flow  under  it ;  then 
the  acetic  acid  is  again  evaporated  very  slowly,  and,  after  it  is  thor- 
oughly dry,  one  or  two  drops  of  distilled  water  are  allowed  to  flow  under 
to  dissolve  any  crystals  of  salt  that  may  be  present.  Under  the 
microscope,  there  can  be  seen  crystals  of  hsemin  (hydrochlorate  of 
hsematin)  in  coffee-brown  or  reddish-brown  crystals  in  rhombic  plates, 
which  must  be  considerably  magnified,  as  the  crystals  are  very  small. 


364  SPECIAL  DIAGNOSIS. 

The  following  method  (an  adaptation  to  the  vomit  of  Heller's  test 
for  blood-coloring  material  in  the  urine,  which  see)  leads  to  a  result 
more  quickly :  We  place  some  of  the  filtered  stomach-fluid  in  a 
reagent-glass,  with  a  like  quantity  of  normal  urine,  make  it  strongly 
alkaline  with  liquor  potassse,  and  heat  it.  The  urine-phosphates  are 
precipitated  and  carry  with  them  the  coloring-material  of  the  blood, 
and  when  blood  is  present,  we  have  a  cloudy,  flocculent,  reddish-brown 
deposit. 

Vomiting  of  pus.  Pus,  as  a  macroscopically  visible  constituent  of 
the  vomit,  is  somewhat  unusual,  and  is  only  observed  in  isolated  cases 
of  phlegmonous  gastritis  or  of  abscess  of  a  neighboring  organ,  breaking 
into  the  stomach.  Probably  it  can  then  only  be  observed  when  it 
pours  into  the  stomach  in  such  quantities  and  so  quickly  that  it 
makes  the  contents  of  the  stomach  alkaline,  for  only  thus  will  it  avoid 
immediate  digestion.    Regarding  separate  white  corpuscles,  see  below. 

Fecal  vomiting  (miserere,  ileus).  In  this  condition,  either  there 
are  considerable  quantities  vomited  which  do  not  look  distinctly 
feculent,  probably  coming  rather  from  the  stomach  or  the  upper 
portion  of  the  small  intestine,  and  the  fecal  addition  is  betrayed  by 
its  odor,  or  there  are  distinctly  fecal  masses,  even  balls  of  excrement. 
This  kind  of  vomit  occurs  in  severe  diffuse  peritonitis  and  in  serious 
occlusion  of  the  bowels  (see  Inspection  and  Palpation  of  the  Abdomen). 
It  indicates  an  extremely  serious  and,  in  most  cases,  fatal  condition ; 
yet  it  does  not  by  any  means  have  the  absolutely  fatal  significance 
which  was  formerly  ascribed  to  it. 

As  visible  admixtures  which  can  be  seen  with  the  naked  eye,  are 
still  to  be  mentioned : 

Round  worms,  which  come  from  the  small  intestine,  probably 
brought  into  the  stomach  by  the  first  efforts  at  vomiting,  and  are 
afterward  seen  in  the  material  vomited  up.  It  is  a  startling  appear- 
ance, but  in  itself  has  no  significance.     Also  : 

Membranous  rags  of  echinococcus,  in  case  one  should  break  into 
the  stomach  from  the  liver  or  spleen.  In  these  cases,  the  microscope 
sometimes  shows  the  scolices  and  hooks  of  the  parasite  (see  illustration, 
p.  183). 

Moreover,  in  individual  cases,  there  are  found  in  the  vomit,  also, 
oxyuris,  anchylostomse,   trichinae  (see  these  under  Stool). 

Microscopical  examination.      This  is  of  very  little   independent 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS. 


365 


value  in  determining  the  processes  of  digestion.  In  vomiting  which 
takes  place  during  digestion,  we,  of  course,  expect  to  find  portions  of 
food  in  very  varying  condition,  according  to  the  time  the  vomiting- 
occurs. 

Starch-grains  in  considerable  quantity,  for  the  time  when  the 
amylolytic  digestive  period  ought  to  be  past,  indicate  incomplete 
amylolysis,  as  is  almost  always  produced  by  hyperacidity  (in  conse- 
quence of  the  too  early  appearance  of  free  muriatic  acid). 

Mucous  corpuscles  are  found  in  watery  and  mucous  vomit;  epithe- 
lium, from  the  mouth,  throat,  oesophagus,  also  sometimes  from  the 
stomach,  is  observed ;  unchanged  red  blood-corpuscles  are  very  rare ; 
in  hemorrhage  of  the  stomach,  the  microscope  generally  is  useless, 
because  the  red  blood-corpuscles  are  broken  up.  Also,  it  is  rare  to 
find  white  blood-corpuscles  that  are  well-preserved. 


Vomited  material  (Jaksch).  a,  Muscular  fibre;  6, white  blood-corpuscle;  c,c!,c", 
flat  and  cylindrical  epithelium;  d,  starch-corpuscles;  e,  fat-globules;  f,  sarcina  ven- 
triculi ;  g,  yeast-ferment;  h,  i,  cocci  and  bacilli  (those  near  h  were  once  found  by  Jaksch 
in  a  case  of  ileus,  hence  arising  from  the  intestine);  k,  fat- needles,  connective  tissue; 
I,  vegetable  cells. 


Sarcina  ventriculi  (schizomycetes)  and  torula  cerevisiae  (yeast-fun- 
gus) are  not  entirely  without  value,  as  indications  that  the  stomach 
retains  its  contents  for  a  long  time,  as,  especially,  in  dilatation. 


366  SPECIAL  DIAGNOSIS. 

Of  the  two  fungi,  the  sarcina  is  the  more  important.  If  it  is  not 
macerated  or  deformed  by  pressure  with  the  covering-glass,  it  is 
generally  easily  recognized,  when  strongly  magnified,  by  its  peculiar 
resemblance  to  a  ball  wrapped  with  a  string  crossing  at  right-angles. 
It  is  stained  a  reddish-brown  by  a  weak  solution  of  iodine,  or  iodide 
of  potassium. 

Torulse  of  diiferent  kinds  and  sizes  (the  latter  very  much  like  a 
small  white  blood-corpuscle,  generally  smaller)  are  easily  distinguished 
as  small  bodies  strung  along  together,  sharply  defined,  which  refract 
the  light  and  are  egg-  or  elliptical-shaped.  Isolated  ones  are  observed 
in  the  contents  of  the  stomach  with  normal  digestion.  When  the 
quantity  is  considerable,  it  shows  that  it  has  been  a  long  time  in  the 
stomach,  whose  contents  have  undergone  alcoholic  fermentation. 

Other  different  kinds  of  bacilli  and  cocci,  which  have  only  recently 
been  carefully  studied,  are  found  in  the  vomit,  but  as  yet  they  have 
no  diagnostic  value. 

Also,  there  are  found  in  the  vomit  aphthae  (probably  originating 
in  the  oesophagus,  see  above)  and  favus  fungus,  achorion  Schonleinii. 

Reaction  of  the  vomit.  This  is  usually  acid  from  muriatic  or 
organic  acids  (see  above,  under  Digestion).  It  may  be  alkaline  when 
a  considerable  quantity  of  blood  is  vomited,  as  in  water-brash,  the 
watery  vomit  of  Asiatic  cholera  ;  also,  rarely,  in  putrid  vomiting,  as 
in  ulcerating  cancer  of  the  stomach,  and  in  the  vomiting  of  kidney- 
disease  (see  below,  under  Odor).  Moreover,  oesophagus-vomiting 
manifests  itself  by  being  always  alkaline  (see  under  Examination  of 
the  (Esophagus). 

Odor  of  the  vomit.  In  many  respects  this  is  very  important. 
Thus,  particularly  the  pi'esence  of  fatty  acids  is  recognized  wath 
great  certainty  by  their  characteristic  pungent  odor. 

The  odor  is  very  important  in  many  poisons,  as  with  phosphorus 
(odor  of  garlic),  bitter  almonds,  or  nitro-benzole  (odor  of  bitter 
almonds),  ammonia,  carbolic  acid,  etc. 

There  is  fecal  odor  with  ileus,  cadaveric  odor  in  ulcerating  car- 
cinoma, also  in  fresh  hemorrhage  of  the  stomach. 

The  odor  is  ammoniacal  in  nephritic  patients,  especially  when  there 
is  uraemia.  It  is  thought  to  result  from  the  separation  of  urea  by  the 
mucous  membrane  of  the  stomach,  by  the  urea  in  the  stomach  changing 
into  carbonate  of  ammonia. 


examination  of  the  digestive  apparatus.        367 
Examination  of  the  Feces. 

As  in  examining  the  contents  of  the  stomach,  the  inquiring  physician 
must  pursue  his  task  from  two  points  of  view  : 

On  the  one  hand,  he  is  to  draw  a  conclusion  from  the  character  of 
the  intestinal  discharges  as  to  the  intestinal  digestion,  and  any  pos- 
sible disturbances  of  it  from  the  abnormal  chemical  changes,  and  also 
an  opinion  regarding  the  present  disease.  On  the  other  hand,  he  is 
to  form  a  diagnosis  directly  from  the  occurrence  of  certain  products 
of  disease,  or  even  of  substances  generated  by  disease,  as  intestinal 
parasites  or  microorganisms  found  in  the  stools.  Unfortunately  an 
explanation  from  the  point  of  view  first  mentioned  is  difficult  for  sev- 
eral reasons  :  first,  because  we  have  to  do  with  the  last  step  of  an 
extremely  complicated  process,  and  then,  in  many  respects,  we  do  not 
sufficiently  understand  this  process  itself,  or  its  pathological  variations. 
With  reference  to  the  other  point,  and  especially  regarding  organic 
exciting  causes  of  disease,  we  have  only  a  few  sure  principles,  part  of 
which  are  old,  and  part  have  only  recently  been  acquired. 

We  have  to  consider  : 

The  intestinal  discharges,  with  reference  to  their  frequency  and 
their  possible,  usually  subjective,  accompanying  symptoms 

The  more  particular  examination  of  the  stools :  quantity,  consist- 
ence, or  form,  color,  odor.  In  addition,  there  are  the  admixtures 
which  are  visible  by  the  naked  eye,  and  those  to  be  seen  only  by  the 
aid  of  the  microscope. 

As  yet,  it  is  not  possible  to  form  an  estimate  of  the  intestinal  diges- 
tion by  the  character  of  the  intestinal  fluid.  It  is  well  known  that 
sometimes  (especially  by  evacuating  the  fasting  stomach)  there  enters 
into  the  stomach  a  fluid  mixed  with  bile  which  is  to  be  regarded  as  a 
mixture  of  pancreatic  and  intestinal  fluids,  since  with  an  alkaline  reac- 
tion it  digests  albumin,  starch  is  changed  into  dextrine  and  maltose,  and 
fat  is  split  up.  But  this  occasional  occurrence  has  not  yet  been  employed 
for  consecutive  examinations.  Boas  recently,  after  carefully  rinsing  out 
the  stomach  with  soda  and  having  it  tightly  squeezed,  has  endeavored, 
by  employing  an  oesophageal  sound,  to  obtain  the  intestinal  juice. 
But  his  results  have  not  yet  been  completely  published  ;  hence  it  is 
not  possible  to  form  an  opinion  as  to  what  assistance  his  method  will 
be  for  the  purposes  of  diagnosis. 


368  SPECIAL  DIAGNOSIS. 

Intestinal  discharges.  In  health  their  frequency  varies  individu- 
ally very  much.  Ordinarily,  at  all  ages,  excepting  nursing  children 
who  have  three  or  four  movements  a  day,  there  is  one  stool  in  twenty- 
four  hours ;  hut  many  persons  regularly  have  a  movement  twice  in 
the  twenty-four  hours,  while  others  only  have  one  in  two  or  three 
days,  or  even  at  longer  intervals,  without  experiencing  any  inconveni- 
ence [or  disorder].  But  in  scarcely  any  other  way  do  physiology  and 
pathology  so  much  encroach  upon  each  other's  limits  as  with  reference 
to  the  frequency  of  the  intestinal  discharges,  for  sometimes  a  move- 
ment even  once  in  two  days  may  be  troublesome,  and  the  physiological 
habitual  constipation,  in  many  cases,  cannot  in  any  way  be  distin- 
guished from  the  pathological  condition. 

Constipation,  or,  better,  pathological  constipation,  is  called  obstipa- 
tion ;  the  expression  obstruction  (severe  obstruction)  is  often  inten- 
tionally used  for  constipation  in  a  serious  sense.  The  opposite  to  this 
condition  is  looseness,  diarrhoea. 

The  frequency  of  the  discharges  is  directly  connected  with  the 
quantity  of  food  taken ;  hence  a  person  who  is  fasting  is  always 
constipated.  This  point  must  often  be  thought  of  The  character  of 
the  food,  too,  has  an  influence  upon  the  frequency  of  the  discharges, 
and  upon  the  passage  of  food  through  the  intestinal  canal.  (See 
under  "quantity.")  Thus  rapid  peristalsis  causes  diarrhoea,  slow 
peristalsis,  obstipation.  Hence,  any  mechanical  obstruction  in  the 
alimentary  canal  brings  on  constipation. 

Diarrhoea  is  the  most  important  sign  of  intestinal  catarrh.  This 
is  brought  about  by  errors  of  diet,  by  cold,  by  infectious  causes,  as 
the  intestinal  catarrh  of  typhus,  dysenteric  inflammation  of  the  large 
intestine,  and  also  many  intestinal  catarrhs  which  were  formerly 
referred  to  the  cause  first  mentioned.  In  this  condition,  the  stools  are 
always  thin  (see  the  second  section  below  and  Consistence  of  the 
Stools) ;  their  frequency  may  be  increased,  even  to  occurring  hourly, 
or  yet  oftener. 

Moreover,  medicines  or  poisons  may  increase  the  peristalsis  alone, 
or  intestinal  catarrh,  and  thus  result  in  diarrhoea. 

In  all  these  cases  the  increased  peristalsis  increases  the  fluidity  of 
the  intestinal  contents,  even  causing  effusion  from  the  intestinal  wall 
into  the  intestinal  cavity  (cholera),  until  we  have  the  condition  of  diar- 
rhoea.   (See  below.) 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  359 

Obstipation  may  be  a  disease  which  is  relatively  harmless,  although 
very  troublesome,  becoming  habitual.  But  it  is  of  much  greater  diag- 
nostic significance,  however,  as  an  early  sign  of  peritonitis  from 
paralysis  of  the  intestine.  Of  still  greater  importance  is  severe  ob- 
struction in  all  forms  of  stenosis  of  the  intestine,  as  fecal  accumulation, 
particularly  in  the  caecum ;  strangulation,  invagination,  intussuscep- 
tion of  the  intestine  :  new  formations,  scars  in  the  intestinal  wall, 
compressing  tumors  external  to  the  intestine  ;  constrictions,  bends 
produced  by  peritoneal  exudations.  In  many  cases  of  chronic  intes- 
tinal occlusion,  as  in  chronic  peritonitis,  constipation  alternates  with 
diarrhoea. 

But  the  condition  of  obstipation  or  diarrhoea  is  still  more  affected 
by  a  possible  increased  or  diminished  abstraction  of  fluid  from  the 
intestinal  contents ;  the  more  fluid  there  is,  the  quicker  it  passes 
through  the  bowel.  Now,  if  the  intestinal  contents  part  with  much 
fluid  when  there  is  slow  peristalsis,  as  a  result  of  prolonged  retention, 
they  become  dry  and  hard,  hence  are  carried  forward  with  difiiculty. 
If  the  peristalsis  is  quicker,  the  contrary  exists.  The  effect  of  slow  or 
quick  peristalsis  is  felt  in  the  transit  [of  the  intestinal  contents],  caus- 
ing either  obstipation  or  diarrhoea. 

The  severest  diarrhoea  occurs  in  cholera  Asiatica,  because  in  this 
disease  there  is  great  eff'usion  of  fluid  from  the  intestinal  wall  into  the 
lumen  of  the  intestine. 

1.  It  is  to  be  understood  that  an  ordinary  constipation  and  severe 
obstruction  are  to  be  sharply  distinguished  from  each  other,  for  a 
quite  ordinary  obstipation  may  be  very  obstinate.  Here  the  decision 
is  made  by  considering  other  phenomena,  as  vomiting,  pain,  and  par- 
ticularly by  examining  the  abdomen.  This  can  never  be  omitted  in 
any  sudden  attack  of  obstipation,  special  attention  being  given  to  the 
hernial  orifices  and  the  caecum. 

2.  Persons  who  eat  little  or.  nothing,  whom  many  things  either 
strangle  (stenosis  of  the  oesophagus),  or  cause  vomiting,  as  in  diseases 
of  the  stomach,  but  especially  pyloric  stenosis,  in  which  case  there  is 
infrequent  but  considerable  vomiting  at  a  time,  cannot  have  frequent 
stools;  hence  they  must  be  obstipated.  Such  cases  are  easily  over- 
looked, particularly  if  the  patients  complain  a  good  deal  of  obsti- 
pation. 

24 


370  SPECIAL  DIAGNOSIS. 

The  special  peculiarities  which  precede  the  examination  of  the 
bowels  are  of  diagnostic  importance  : 

Pain  with  the  movements.  There  will  be  pain  at  the  anus  or  at 
the  lower  portion  of  the  abdomen  in  all  kinds  of  inflammatory  affec- 
tions of  the  anus,  the  rectum,  or  their  neighborxiood.  We  have  severest 
pain  when  the  lower  portion  of  the  rectum  is  compressed  by  a  large 
inflammatory  (purulent)  exudation,  especially  in  the  exudation  of  peri- 
and  para-metritis  ;  also  in  fissure  of  the  anus  and  abscesses  from 
peri-proctitis  (see  Surgery).  Likewise,  in  carcinomatous,  syphilitic, 
gonorrhoeal  stenosis  of  the  rectum,  but  also  in  the  usually  harmless 
hemorrhoids,  the  pain  at  stool  is  characteristic.  Sometimes  in  all 
these  conditions,  and  particularly  in  all  inflammations  of  the  large 
intestine,  but  most  pronounced  in  dysentery,  there  is  usually  painful 
straining  at  stool,  and  pain  after  it — tenesmus.  Whenever  there  is 
pain  at  stool  there  must  be  a  careful  inspection  of  the  anus  and  pal- 
pation of  the  rectum. 

Involuntary  discharges  of  the  bowels,  incontinentia  alvi,  are  most 
frequently  dependent  upon  the  cloudiness  of  intelligence  which  ac- 
companies any  severe  disease ;  but  they  may  result  from  paralysis, 
particularly  in  diseases  of  the  spinal  cord.  If  the  stools  are  thin, 
then  incontinence  occurs  with  less  loss  of  intelligence  than  if  they  are 
firm.  Slight  incontinence  manifests  itself  sometimes  by  the  fact  that 
the  patient  must  hasten  to  go  to  stool  as  soon  as  he  has  the  impulse. 
Incontinentia  is  opposed  to  retentio  alvi  as  regards  its  neurotic  origin. 
(See  Examination  of  the  Nervous  System.) 

Physical  and  chemical  peculiarities  of  the  feces.  Assuming  an 
unobstructed  passage,  the  amount  of  the  stools  is  determined  by  the 
quantity  and  quality  of  the  food  taken.  In  the  latter  respect  it 
depends  upon  how  much  of  the  food  is  digested  and  taken  up  ;  hence, 
all  vegetable  foods  make  copious  stools. 

Also,  the  quantity  of  the  stools  is  increased  in  diarrhoea,  because 
too  little  of  the  fluid  portion  of  the  intestinal  contents  is  taken  up. 
The  greatest  increase  occurs  in  cholera,  from  the  eff"usion  of  quantities 
of  fluid  into  the  intestine. 

Enormous  quantities  of  firm,  solid  stools  may  be  passed  after  pro- 
longed obstipation  or  serious  obstruction. 

We  may  form  an  estimate  from  the  amounc  of  the  stools,  or  of  their 
weight,  of  the  resorption  of  food,  if  we  know  how  much  of  resorbable 


EXA  MINA  TION  0  F  THE  DIG  ES  TI VE  A  PPA  RA  TUS.  371 

substances  the  food  taken  contains,  and  if  we  can  decide  that  a  par- 
ticular stool  comes  from  the  food  taken  within  the  period  of  observa- 
tion, by  the  admixture  of  substances  which  give  a  distinctive  color. 
However,  Ave  neglect  the  addition  made  to  the  feces  during  digestion 
from  the  digestive  juices.  On  the  one  side,  there  is  a  too  rapid  move- 
ment of  the  food  along  the  alimentary  canal,  and,  on  the  other,  dis- 
turbance of  the  resorption  of  the  food.  We  learn  from  the  recent 
investigations  of  F.  Miiller,  that  in  mild  enteritis  and  in  mild  amyloid 
degeneration  only  the  fat,  but  in  severe  cases  of  disease  of  the  mucous 
membrane  all  the  nutritive  material,  is  poorly  resorbed ;  further,  that 
a  deficiency  of  pancreatic  juice  makes  no  special  disturbance;  defi- 
ciency of  bile  and  tuberculosis  of  the  lymphatic  glands  disturb  the 
absorption  of  fat  (see  below) ;  finally,  that  absorption  is  only  slightly 
disturbed  by  accumulation  in  the  intestinal  canal. 

Consistence^  or  form  of  the  stool.     Normally,  it  is  firm  or  mushy. 

The  fact  has  already  been  stated,  and  the  reason  given,  why  in 
diarrhoea  the  stool  is  more  or  less  thin,  or  like  thin  soup.  The  stool 
may  really  be  watery,  as  in  cholera  Asiatica,  but  also  in  all  severe 
acute  cases  of  enteritis,  also  in  dysentery.  The  dried  fecal  balls 
which  are  passed  with  or  after  obstipation  are  very  hard. 

The  form  of  firm  feces  does  not  have  any  independent  value. 
Especially  the  stool  which  is  like  the  stool  of  sheep  (small,  hard  balls, 
about  the  size  of  a  cherry)  is  not  characteristic  of  stenosis  of  the 
rectum,  because  it  also  occurs  in  ordinary  constipation.  Band-like 
flat  scybala  rather  indicates  stenosis,  more  especially  compression  of 
the  rectum  antero-posteriorly. 

'  Here  may  be  mentioned  the  arrangement  in  layers  of  the  thin  and 
the  mushy  stools  which  not  infrequently  are  met  with.  In  these  the 
firm  portions  settle  so  that  the  upper  part  of  the  stool  consists  of  a 
clear  watery  layer.  This  is  the  kind  of  stool  we  have  in  typhus 
abdominalis  [typhoid  fever],  but  we  also  have  it  in  other  thin  stools, 
and  it  is  very  commonly  a  result  of  the  admixture  of  urine. 

Odor  of  the  stools.  The  variations  from  the  normal  fecal  odor  not 
infrequently  have  distinct  diagnostic  value.  In  nursing  children  a 
slightly  sour  odor  is  normal. 

The  alcoholic  stool  is  offensive,  but  does  not  always  really  have  a 
foul  odor.  An  odor  like  fatty  acids  (and  acid  reaction  from  acid  fer- 
mentation) is  peculiar  to  the  slight  forms  of  infantile  diarrhoea.     A 


372  SPECIAL  DIAGNOSIS. 

decidedly  foul  smell  (putrid  albumin,  alkaline  fermentation)  belongs 
to  severe  forms  of  this  disease.  The  stools  of  cholera  and  dysentery 
often  smell  flat,  like  semen  (cadaverin,  Brieger).  Cadaverous,  foul, 
stinking  stools  characterize  gangrenous  dysentery,  carcinomatous  or 
syphilitic  ulceration  of  the  rectum.  When  blood  or  pus  is  mixed 
with  the  stool  in  considerable  quantities  the  fecal  odor  may  be  masked 
and  replaced  by  a  mild,  stale  odor.  Often  the  stool  is  ammoniacal, 
from  admixture  Avith  urine  which  has  decomposed. 

Reaction  of  the  stools.  Only  iu  children,  particularly  nurslings 
(in  whom  it  is  normally  slightly  acid)  is  the  reaction  diagnostic,  and 
gives  important  indications  for  treatment.  Decided  acid  reaction  is 
observed  in  acid  fermentation  in  the  intestinal  canal ;  alkaline  reac- 
tion in  alkaline  fermentation  with  putrid  albumin.  In  both  condi- 
tions there  is  intestinal  catarrh. 

Color,  constituents,  admixtures  of  the  stools  (so-  far  as  they 
can  be  recognized  by  the  naked  eye).  The  normal  color  of  the 
stools  varies  from  bright-  to  blackish-brown.  It  is  in  part  due  to  the 
addition  of  bile  (that  is,  products  of  decomposition  of  the  coloring 
matter  of  the  bile,  particularly  hydrobilirubin),  and  partly  to  the  food. 
By  the  latter,  the  stool  may  be  unusually  colored,  as  by  huckleber- 
ries, which  color  it  black,  and  may  be  confounded  with  blood. 

In  the  normal  stool,  portions  of  food  can  be  recognized  with  the 
naked  eye,  if  things  that  cannot  be  digested — like  cherry-stones, 
particles  of  wood,  etc. — have  been  swallowed.  We  also  see  grape- 
seeds,  the  skin  of  many  kinds  of  fruit,  etc.  Large  fibres  of  con- 
nective-tissue, undigested  portions  of  grains,  mushrooms,  etc.,  may 
sometimes  be  met  with  in  the  stools,  if  the  patient  has  eaten  rapidly 
or  has  swallowed  his  food  in  quantities.  With  the  naked  eye,  we 
can  see  fibres  and  pieces  of  undigested  substances,  the  old  designa- 
tion for  which  was  lientery,  like  portions  of  muscle,  flocks  of  casein, 
in  the  stools  of  children  ;  sometimes  somewhat  friable,  perhaps  slimy  ; 
or  even  portions  of  starch.  All  of  these  indicate  disturbance  of" 
digestion  in  the  small  intestine,  or  also  in  the  stomach,  as  is  seen  in 
intestinal  catarrh,  or  catarrh  of  the  stomach,  or  in  the  dyspepsia  of 
fever,  with  increased  peristalsis. 

In  the  rare  condition  of  communication  between  the  stomach  and 
colon  (perforating  ulcer  of  the  stomach),  we  find  the  coarsest  admix- 
ture of  digestible  portions  of  food  in  the  stool. 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  373 

Occasionally,  extraordinary  forms  of  remains  of  vegetables  (orange- 
like, etc.)  have  given  rise  to  mistake.  With  children,  hysterical 
persons,  and  imbeciles,  we  must  be  prepared  for  all  sorts  of  pre- 
posterous foreign  bodies  in  the  stools. 

The  stools  of  nurslings  and  of  adults  who  live  upon  milk  illustrate 
the  appearance  of  the  stool  when  colored  only  by  bile-pigment.  Firm 
stools  are  generally  darker  than  thin  ones,  because  more  concentrated. 
In  severe  diarrhoea,  but  especially  in  cholera,  dysentery,  also  severe 
enteritis,  after  the  first  evacuations  have  swept  out  the  intestinal  con- 
tents, the  stools  always  become  brighter,  afterward  grayish-white  and 
watery,  or,  in  dysentery,  colored  by  blood,  etc. 

When  there  is  diminished  flow  of  bile  into  the  intestine,  as  occurs 
in  hepatogenous  icterus,  the  stools  are  lighter.  If  the  bile  is  cut  off, 
they  are  grayish-white,  clayey,  and  faintly  glistening.  This  is  due 
not  alone  to  the  want  of  the  transformation  of  the  bile-pigment,  but 
also,  it  would  seem,  chiefly  to  the  large  amount  of  fat  in  the  so-called 
acholic  stools.  The  increased  amount  of  fat,  in  turn,  shows  dimin- 
ished digestion  of  the  fat,  due  to  the  deficiency  of  bile. 

We  designate  as  bilious  stools  those  which  contain  the  coloring- 
matter  of  the  bile  unchanged.  A  quick  passage  of  the  contents  of 
the  intestine,  and  profuse  diarrhoea,  always  bring  about  this  kind  of 
stool.  We  see  it  most  frequently  in  acute  intestinal  catarrh,  especi- 
ally in  children ;  perhaps  there  is  here  also  an  increased  effusion  of 
bile.  The  bilious  stool  is  bright-yellow,  green-yellow,  or  green,  and 
has  the  reaction  of  the  coloring-matter  of  the  bile.  We  filter  it,  and 
treat  the  filtrate  as  we  do  when  testing  for  bile  in  the  urine  (which 
see). 

Mucous  stool.  When  mucus  can  be  distinctly  recognized  in  the 
evacuations  of  the  bowels,  it  always  indicates  catarrh  of  the  mucous 
membrane  of  the  intestine,  and  hence  something  pathological ;  though 
in  many  cases  the  disturbance  in  the  intestines  may  be  regarded  as 
without  significance.  There  are  unnoticeable  transitions  from  the 
normal  secretion  of  mucus  by  the  intestine  to  a  decided  stimulation  by 
chemical  or  mechanical  irritation,  even  to  a  true  enteritis.  Nothnao-el 
considers  that  small,  visible  particles  of  mucus  interspersed  in  firm 
stools   belong  to  a  normal  condition. 

Larger  masses  of  mucus,  in  the  form  of  more  or  less  thick  shreds, 
always  indicate  with  greater  probability  a  catarrh  of  the  large  intestine. 


374  SPECIAL    DIAGNOSIS. 

Certain  small,  roundish  particles  of  mucus,  like  sago  granules,  are  said 
to  come  usually  from  this  portion  of  the  intestine.  Catarrh  of  the  large 
intestine  then  can  be  definitely  diagnosed  from  the  stools,  if  firm  fecal 
balls  are  passed  which  are  covered  with  mucus.  Sometimes  we  find 
spread  over  the  scybalaa  layer  of  thick,  tough  mucus.  An  abundant 
admixture  of  mucus  in  thin  stools  occurs,  especially  in  acute  intestinal 
catarrh,  if  the  large  intestine  is  also  aifected,  and  in  catarrhal 
dysentery. 

We  designate  as  intestinal  infarction  cylindrical  tubes  which  consist 
entirely  of  mucus  (or  partly  of  fibrine),  and  which  form  casts  of  the 
large  intestine.  In  rare  cases  they  occur  in  chronic  catarrh  of  the 
large  intestine,  and  are  usually  passed  with  great  pain  (mucous  colic). 

If  there  are  fine  and  equal  portions  of  mucus  in  solid  fecal  balls, 
we  then  think  of  catarrh  of  the  small  intestine.  But,  also,  mucus 
occurring  in  thin  stools  may  have  its  origin  in  the  small  intestine.  Then 
it  is  usually  finely  divided,  and  is  soft.  In  cholera  Asiatica  (also  in 
cholera  morbus)  the  stools  are  watery,  and  contain  particles  of  mucus 
which  look  like  boiled  rice  (rice-water  stools). 

Nothnagel  utters  a  warning  against  regarding  all  small,  slimy-look- 
ing particles  in  the  stools  as  mucus.  They  may  come  from  the  food. 
The  chemical  reaction  determines  in  a  doubtful  case. 

Watery  stools.  To  these  we  have  already  referred  repeatedly. 
They  occur  in  severe  acute  intestinal  catarrh,  in  dysentery,  and  in 
cholera  Asiatica,  and  express  profuse  diarrhoea,  by  which  the  intestinal 
contents  are  completely  expelled.  Even  bile,  or  its  transition  products, 
are  not  usually  found  in  watery  stools. 

Fatty  stool.  This  is  usually  recognized  by  its  slightly  glistening, 
and  its  greasy  look.  When  there  is  much  fat,  the  stools  are  clayey- 
looking,  or  whitish,  even  Avhen  the  bile  is  not  cut  off  from  the  intes- 
tine. When  the  stool  contains  considerable  fat,  moreover,  it  has  the 
peculiarity  of  becoming  softer  and  more  glistening  with  the  eleva- 
tion of  the  temperature  of  the  body.  For  further  regarding  fatty 
stool  and  its  occurrence,  see  under  Microscopical  Examination. 

Bloody  stool.  This  has  an  extremely  variable  appearance,  dependent 
upon  the  more  or  less  change  in  the  blood,  and  whether  it  is  not  at  all, 
or  is  intimately,  mixed  with  the  feces. 

When  firm  scybala  are  covered  over  with  blood,  it  indicates  hemor- 
rhage of  the  rectum,  or  large  intestine.     If  the  blood  does  not  look 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  375 

at  all  changed,  it  is  from  the  rectum  or  anus.  When  there  is  an 
admixture  of  blood  with  thin  stools,  if  the  blood  retains  its  color,  and 
is  not  intimately  mixed  with  feces,  mucus,  or  pus,  it  points  with 
tolerable  certainty  to  the  large  intestine  or  anus.  However,  there  may 
be  intimate  mixture  of  blood  even  in  hemorrhage  from  the  large 
intestine,  and  in  watery  stools,  as  in  meat-juice  stools  in  dysentery, 
and  in  severe  catarrh  of  the  large  intestine  in  children. 

Hemorrhage  of  the  large  intestine  occurs  most  frequently  with 
hemorrhoids  in  the  lower  portion  of  the  rectum,  carcinomatous  ulcera- 
tion, again  chiefly  from  the  rectum,  and  in  other  ulcerations  of  the 
large  intestine  of  any  kind,  as  in  dysentery. 

When  the  blood  is  intimately  mixed  with  the  feces,  it  indicates 
hemorrha";e  from  the  small  intestine  or  from  the  stomach.  Besides,  in 
this  case  the  blood  is  usually  more  or  less  changed,  brownish-red,  even 
deep-black,  the  color  of  tar,  from  breaking  up  of  the  red  corpuscles 
and  of  haemoglobin  (formation  of  sulphate  of  iron  ?). 

The  degree  of  change  which  the  blood  undergoes  depends  upon  the 
length  of  time  it  has  been  in  the  intestinal  canal,  and  the  way  in 
which  it  is  mixed  with  the  feces.  There  is  the  least  change,  the  blood 
sometimes  remaining  red,  with  preservation  of  the  red  corpuscles, 
when  a  large  quantity  of  blood  from  the  lower  part  of  the  ileum  passes 
quickly  into  the  colon,  because  of  existing  diarrhoea.  This  happens 
with  the  profuse  hemorrhage  of  the  bowels  in  typhus  abdominalis. 
Blood  which  comes  from  the  stomach,  duodenum  (in  ulcer  of  the 
stomach,  ulcus  duodenale)  becomes  as  black  as  tar  before  it  is  evacu- 
ated, because  of  its  slow  transit  and  the  usual  absence  of  diarrhoea. 
Moreover,  with  gastric  hemorrhage,  the  blood  may  appear  in  the  stool 
like  coifee-grounds  (see  above,  p.  363). 

In  most  cases,  in  order  to  prove  the  existence  of  blood,  it  does  not 
suffice  merely  to  examine  with  the  naked  eye.  Then  we  employ  the 
microscope  to  make  out  the  red  blood-corpuscles,  and  if  they  are 
bi'oken  up,  then  it  is  necessary  to  test  for  hsemin.    (See  above,  p.  363.) 

1.  We  have  already  repeatedly  spoken  of  the  importance  of  giving 
continued  attention  to  the  stools  whenever  there  is  a  suspicion  of 
hemorrhage  in  the  alimentary  canal.  This  obtains  particularly  with 
ulcer  of  the  stomach  or  duodenum. 

2.  It  is  evident  that  any  blood  which  reaches  the  stomach,  having  its 
origin  in  the  oesophagus,  or  coming  from  farther  up  and  being  swallowed, 


376  SPECIAL  DIAGNOSIS. 

may  appear  in  the  stools  (see  examination  of  the  nose,  expectoration, 
oesophagus). 

Purulent  stools.  A  considerable  quantity  of  pure  pus  is  not  so  very 
rare,  happening  as  a  sign  of  a  rupture  somewhere  of  a  collection  of 
pus  (generally  of  a  parametric  exudation)  into  the  intestines,  especially 
the  rectum.  Therefore,  whenever  there  is  a  febrile  affection  of  the 
abdomen,  where  the  formation  of  the  pus  is  either  made  out,  or  at  least 
is  thought  to  be  possible,  we  ought  always,  but  especially  if  there  has 
been  a  sudden  decline  of  the  fever,  carefully  to  examine  the  stools  as 
well  as  the  urine  (which  see). 

Moreover,  dysenteric,  catarrhal,  syphilitic,  and  carcinomatous,  ulcera- 
tions of  the  large  intestine  produce  some,  or  possibly  considerable, 
accumulation  of  pus,  according  to  their  extent ;  likewise,  periproctitic 
abscesses. 

Gall-stones,  enteroliths.  The  former  come  either  from  the  galL 
bladder  or  the  intrahepatic  gall-passages  (intrahepatic  stones,  much 
smaller  than  the  others,  rare)  through  the  ductus  choledochus,  and,  as 
they  come  into  the  intestine,  often  produce  severe  colic  and  jaundice. 
Whenever  there  is  abdominal  colic,  particularly  if  it  is  connected  with 
jaundice,  and  generally  whenever  there  is  jaundice,  we  must  look  out 
for  gall-stones  in  the  stools.  In  rare  cases,  if  there  is  suppuration  of 
the  gall-bladder,  they  come  from  the  gall-bladder,  there  being  adhesion 
with  the  colon,  into  which  they  break,  and  thus  directly  reach  the 
intestine. 

When  we  are  looking  for  gall-stones  the  stool  must  be  passed 
through  a  sieve.  If  it  is  formed  or  mushy,  it  must  be  broken  up  by 
pouring  a  stream  of  water  upon  it.  The  gall-stones  are  generally 
very  easily  recognized  by  their  shining  appearance,  smooth  surface, 
and  many  angled  (facets)  form.  Small,  especially  intrahepatic, 
stones'  may  not  have  facets,  and  be  more  crumbling.  They  consist 
chiefly  of  cholesterin,  and  also  contain  coloring  matter  of  the  bile. 

Enteroliths  are  rare.  They  usually  come  from  the  vermiform 
appendix,  and  their  centre  commonly  consists  of  solid,  undigested 
portions  of  food,  as  a  cherry-stone,  around  which  have  been  deposited 
some  lime  or  magnesium  salts. 

Portions  of  tissue  from  the  intestinal  canal.  In  very  rare  cases, 
when  there  is  invagination  of  the  intestine,  the  whole  of  the  portion 
that  is  turned  in  sloughs  off,  the  intestine  forming  new  adhesions, 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  377 

and  thus  life  is  preserved.    This  entire  piece  may  appear  in  the  stool. 

Shreds  of  mucous  membrane  from  the  large  intestine  in  dysentery, 

portions  of  tissue  of  carcinoma,  or  other  new  formations,  may  appear 

in  the  stools. 

Animal  Parasites. 

In  what  follows  it  will  be  shown  that  some  of  the  animal  parasites 
that  exist  in  the  human  alimentary  canal  have  no  pathological  signifi- 
cance ;  others,  on  the  other  hand,  are  very  important  factors  as  excitors 
of  disease.  The  examination  for  these  latter  or  for  their  eggs  cannot 
be  made  too  frequently,  or  too  carefully.  An  examination  of  the  stools 
for  parasites  must  be  undertaken  not  alone  when  there  are  complaints 
or  symptoms  which  directly  indicate  intestinal  parasites,  or  in  general 
Avhen  there  are  evidences  of  intestinal  catarrh,  but  in  any  case  of 
anaemia,  when  there  is  any  general  nervous  depression,  in  certain  other 
phenomena  of  the  nervous  system  (see  works  upon  pathology),  if  the 
cause  of  the  particular  complaint  does  not  appear  to  be  clear.  The 
cases  are  numberless  where,  after  long  fruitless  search  elsewhere,  the 
discovery  of  a  joint  of  a  tapeworm,  for  instance,  leads  to  the  correct 
apprehension  and  treatment  of  the  patient. 

In  order  not  to  separate  what  belongs  together,  we  collect  here  all 
that  is  to  be  said  regarding  the  occurrence  of  intestinal  animal  para- 
sites and  their  eggs  in  the  stools,  whether  in  the  examination  we 
employ  the  naked  eye,  the  simple  or  the  compound  microscope. 

Tape-worm  {eestodes).  Its  habitat  is  exclusively  the  small  intes- 
tine. It  gives  rise  to  very  great  pathological  disturbances  (intestinal 
catarrh,  anaemia,  nervous  manifestations  of  varying  severity).  It 
consists  of  a  very  small  head  and  neck,  and  a  ribbon  of  flat  joints 
(proglottides),  several  meters  long,  which  constantly  push  oif  at  the  end 
of  the  worm,  and  grow  again  from  above.  It  clings  to  the  wall  of 
the  intestine  by  its  head. 

It  can  be  recognized  by  a  single  joint,  which  can  easily  be  seen 
with  the  naked  eye,  or  by  the  presence  of  eggs  in  the  stools  (micro- 
scopical examination). 

1.  Tcenia  solium.  This  is  2  or  3  meters  long.  Its  head  is  the 
size  of  the  head  of  a  pin,  glistening  gray  ;  the  jest  of  the  worm  is 
white,  or  yellowish-white.  Upon  the  head  ai'e  four  pigmented  suck- 
ing cups  (to  be  seen  with  a  simple  microscope),  which  surround  ;? 
crown  of  chitin  hooks.  ''  crown  of  hooks."     The  ripe  proglottides — 


4l\ 


SPECIAL  DIAGNOSIS. 


that  is,  those  on  the  lower  end  of  the  worm — are  about  10  mm.  long, 
•5  or  6  mm.  broad,  and  are  like  gourd-seods  (but  are  smaller).  From 
the  peculiarity  of  these  ripe  joints,  which  are  continuously  thrown  off 
and  passed  with  the  stool,  we  are  able  to  make  the  differential  diagnosis 


Fig.  94. 


Fig.  95. 


Fig  94. — TaBnia  solium,  head  enlarged.     (Heller.) 

Fig.  95. — Taenia  solium.     Ripe  joint,  magnified  C  times.     (Heller  ) 

Fig.  96. — Egg  of  taenia  solium.     (Heller.) 


between  this  and  the  other  tape-worms.  The  joints  show  a  longitu- 
dinal canal  (the  uterus),  from  which,  toward  both  sides,  as  many  as  a 
dozen  branches  go  off  which  ramify  like  the  branches  of  a  tree. 

The  eggs  of  T.  solium  (which  require  the  use  of  a  moderate  micro- 
scopic power  in  order  to  find  them,  stronger  to  examine  them  care- 
fully) are  round,  and,  if  they  are  ripe,  have  very  thick  shells  (which 
show  radiating  lines,  and  which,  with  a  little  pressure  upon  the  cov- 
ering glass,  break  into  hard  pieces.  In  the  finely  granular  contents 
we  often  see  a  few  chitin  hooks. 

2.  The  Taenia  mediocanellata,  seu  sagiyiata,  grows  to  4  or  5  meters. 
The  head  is  somewhat  larger  than  that  of  the  solium,  is  also  more 
strongly  pigmented.  It  has  no  crown  of  hooks,  but  four  sucking 
cups,  which  are  much  stronger  than  those  of  the  solium.  On  the 
whole,  the  rest  of  the  worm,  as  respects  its  individual  joints,  is  fatter 
and  thicker  than  the  first-named.  The  ripe  proglottides  are  passed, 
not  only  by  the  stool,  but  wander  independently  from  the  anus,  having 
strong,  very  energetic,  independent  movements.  They  are  distin- 
guished from  the  T.  solium  in  that  the  uterus  gives  off  more  and  finer 
branches  on  each  side,  which  divide  dichotomously. 


EXAMIXATIOX  OF  THE  DIGESTIVE  APPARATUS. 


379 


The  egg  of  the  T.  mediocanellata  looks  extremely  like  that  of  the 
T.  solium,  except  that  on  the  average  it  is  some"n"hat  larger. 


Fig.  97. 


Fig.  9S. 


Fig.  99. 


Fig.  97.  — Tisuia  mediocanellata.     Head  darkly  pigmented.     (Heller.) 
Fig.  98. — Tffinia  mediocanellata.     Eipe  joint,  magnified  6  times.     i^Heller.) 
Fig.  99. — Egg  of  twnia  mediocanellata.     (Heller.; 

3.  Bothriocephalus  lata  (sinus  head)  is  found  in  Germany,  only 
in  the  neighborhood  of  the  North  and  East  Seas,  of  Lake  Geneva, 
and  in  Northwestern  Russia  [Sweden,   Poland,  Belgium.  Holland. 


Fig.  100. 


Fig.  101. 


Fig.  102. 


Fig.  103. 


Fig.  100. — Head  of  bothrioceplialus  latns.     (Heller.) 

Fio-.  101.— Ripe  joint  of  botlirioeephalus  latus  enlarged  six  times.     (Heller.) 

Fig.  102. — Egg  of  bothriocephalus  latus.     (Heller.) 

Fig.  ]  0.3.— Egg  of  bothriocephalus  latus.  with  developed  embryo.     (LErcKARX.) 

''Low-lying  damp  regions  near  the  borders  of  seas  and  lakes  are  those 
in  which  it  is  most  often  abundant."]     It  is  the  largest  of  the  tape- 


380 


SPECIAL  DIAGNOSIS. 


worms,  and  reaches  to  7  or  8  meters  in  length.  Its  head  is  elongated, 
and  has  two  narrow,  long-drawn  out  sucking  cups.  The  illustration 
shows  its  form  and  the  shape  of  the  uterus. 

The  ripe  joints  are  not  given  off  singly,  but  a  large  piece  of  the 
worm  is  always  passed  at  one  time,  and  then,  after  a  long  interval, 
another ;  most  frequently  in  the  spring  and  fall. 

For  this  reason  we  here  refer  to  the  finding  of  the  eggs  (which  are 
always  present  in  the  stools).  They  are  oval  (see  Fig  102),  and  much 
larger  than  those  of  two  other  kinds  of  tape-worm.  The  shell  is 
bright  brown,  relatively  thin,  and,  on  one  end  of  the  oval,  has  an 
opening  which  is  closed  with  a  cover  of  exactly  the  same  kind.  The 
contents  of  the  egg  are  granular. 

As  has  recently  become  known,  the  bothriocephalus  gives  rise  to 
severe  anaemia,  with  changes  in  the  blood  like  those  in  severe  per- 
nicious anaemia ;  for  this  reason,  and  because  there  are  no  joints 
thrown  off,  this  tape-worm  is  very  easily  overlooked  for  a  long  time. 

4.  Taenia  cucumerina,  5-20  cm.  long,  2  mm.  wide;  the  head  is 
somewhat  long,  and  has  sixty  hooks;,  the  last  joints  are  reddish,  and 
have  the  form  of  pumpkin  seed.  Six  to  fifteen  of  the  eggs  lie  together 
in  the  so-called  cocoon.  It  occurs  in  dogs,  cats,  and  not  infrequently 
in  men,  especially  children  (Leuckart).  Its  pathological  significance 
is  not  known.     (See  Fig.  104.) 

Fig.  ]  04. 


Taenia  cucumerina  (BtRCH-HiRSCHFELD).     a,  joint,  natural  size ;  b,  enlarged 
12  times;   c,  cocoon,  enlarged  290  times. 

Round  worms — Ascaris  lumbricoides.  This  is  easily  recognized 
from  its  likeness  to  the  common  earth-worm.  Its  habitat  is  the  small 
intestine.  Very  frequently  it  gives  rise  to  little  or  no  complaint,  but 
it  sometimes,  and  especially  in  children,  causes  very  uncomfortable 
phenomena  of  all  sorts,  particularly  of  the  nervous  system.  Occa- 
sionally, when  there  is  severe  vomiting  [and  sometimes  when  there 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS. 


381 


has  not  been  any  vomiting  at  all],  it  gets  into  the  stomach  and  is  then 
vomited.  Moreover,  it  may  crawl  into  the  ductus  choledochus,  and 
thus  cause  obstinate  jaundice.  These  worms  appear  in  the  stools ;  and 
sometimes,  in  sleep,  they  will  crawl  out  of  the  anus.  They  are  said 
sometimes  to  come  out  of  the  mouth  and  nose  while  the  person  is 
sleeping. 

The  fresh  eggs  of  the  ascaris  lumbricoides  have  a  very  peculiar 
appearance,  since  its  chitin  capsule  is  covered  wdth  an  uneven,  as  it 
were,  humped  albuminous  envelope.  (See  Fig.  105.) 


Fig.  105. 


Fig.  108. 


Fig.  105. — Ascaris  lumbricoides  (Jaksch).     a,  -worm  natural  size;  b.  head-  c,  egg. 
Fig.  106. — Oxyuris  vermicularis.     Natural  size.     1,  female;  2,  males. 
Fig.  107. — Egg  of  oxyuris  vermicularis  (enlarged). 

Fig.  108.— Oxyuris  vermicularis,  enlarged,     a,    ripe,    but    unimpregnated    female; 
b,  male  ;  c,  female  containing  eggs. 


382 


SPJECJAL  DIAGNOSIS. 


Oxyuru  vermieuJaris  is  a  small,  -white  -R-orm  (Fig.  106)  found 
particularly  in  the  large  intestine.  It  may  wander  from  the  anus  into 
the  Tagina.  It  has  very  slight  pathological  significance.  It  appears 
in  the  stools,  and  also  it  is  not  infrequently  found  by  itself  in  the 
neighborhood  of  the  anus.  When  first  passed,  it  has  usually  ver\" 
lively  peculiar  movements.  The  eggs  are  commonly  unsymmetrical. 
(See' Fig.  107.) 

Anchylostoma  diwd^nale,  very  like  the  last  in  form,  but  often 
longer,  even  twice  as  long :  usually  inhabits  the  upper  part  of  the  small 
intestine,  especially  the  duodenum. 

Formerly  it  was  only  observed  in  other  countries  [discovered  by 
Dubini  in  1838.  in  northern  Italy],  more  recently  also  in  Switzerland 
(first  during  the  building  of  the  St.  Gothard  tunnel),  and  finally  it  was 
noticed  among  brickmakers.  Because  it  continually  sucks  blood  from 
the  wall  of  the  intestine,  it  causes  severe,  sometimes  fatal,  anaemia 
(anchylostomiasis,  formerly  "Egyptian-chlorosis,"'  Griesinger).  It  is 
difficult  to  discover  the  worms  in  the  stools  unless  some  vermifuge  is 
■Qsed,  but,  on  the  other  hand,  the  tolerably  characteristic  eggs  are  always 
present.      They  are  as  large  as,  or  perhaps  a  little  larger  than,  those  of 

Fig.  109. 


Anchylostoma  duodenale  (Jaksch).     a.  male:  b,  female,  natural  size ;  e,  male; 
d.  female,  slightly  magnified:  e,  head;  /,  egg. 

the  oxyuris.     They  have  a  thick  covering,  and  contain  two  or  more 
segmentation  globules.     By  allowing  the   stool  to  stand  for  several 


EXAMISATIOX  OF  THE  DIGESTIVE  APPARATUS.  333 

days  in  a  warm  place,  we  can  see  the  embryos  develop  in  the  eg^s. 
In  this  very  serious  disease  the  stools  often  contain  blood. 

Besides  the  intestinal  parasites  already  mentioned,  there  are  the 
following,  part  of  which  are  pathologically  unimportant,  and  others 
'are  very  rare : 

Tricocepliahis  dkpar.  Its  habitat  is  the  colon,  especially  the 
caecum.  It  is  of  no  importance.  Both  the  worms  and  eggs  are  highly 
characteristic  in  form.     (See  Figs.  llU  and  111.) 

Fig.  110. 


Fig.  110. — Trichoeephalus  dispar,  natural  size.    (Hellee.) 
Fig.  lll.^-Egg  of  triehocephalus  dispar,  moderatelv  enlarged. 

TricJiina  spiralis.  It  very  rarely  occurs  in  the  intestine,  but  some- 
times in  the  first  stage  of  the  trichinosis,  the  stomach-stage,  with 
intestinal  phenomena,  it  is  found  in  the  stools.  Since  the  early  recog- 
nition of  trichinosis  is  of  the  greatest  importance,  in  a  suspicious  case 
the  stool  is  to  be  examined  with  the  greatest  care,  best  after  the  adminis- 
tration  of  an  aperient. 

The  appearance  of  the  intestinal  trichina  is  shown  in  Fig.  112.  It 
is  onlv  one-third  as  lonsr  as  the  o-Tviiris,  and  hence  cannot  be  seen  with 
the  naked  eye. 

Distoma  Jiepaticum  and  D.  lanceolatum,  two  rare,  but  pathologi- 
cally important,  parasites,  which  inhabit  the  gall-passages  of  the  liver, 
sometimes  make  themselves  known  by  their  eggs,  which,  passing  out 
into  the  intestine  with  the  bile,  appear  in  the  stools.  The  egg  of  the 
D.  hepaticum  is  much  larger  than  the  other  parasites  previously  men- 
tioned, about  three  times  as  large  as  thos^  of  ascaris  lumb.  The  egg 
of  the  D.  lanceolatum  is  somewhat  smaller  than  that  of  the  oxyuris. 
For  its  other  characteristics  see  Fig,  114. 

Infusoria  of  very  gi'eat  variety  of  species  are  found  in  the  stools  of 
all  kinds  of  diarrhoea:    in  acute  and  chronic  intestinal  catarrh,  in 


384 


SPECIAL  DIAGNOSIS. 


typhoid  fever,  in  tuberculosis  of  the  intestine.  Immediately  after  the 
evacuation  of  the  bowels  they  manifest  very  active  movement.  Their 
pathological  and  diagnostic  significance  are  both  negative. 


Fig.  112. 


Fig.  113. 


Fig.'112. — Adult  intestinal  trichina,  human.  Male,  female,  and  two  embryos  slightlv 
magnified.    (Biech-Hirschfeld.) 

Fig.  lis. — Trichina  (Jaksch.;  a,  male;  h,  female  intestinal  trichina;  c.  muscle 
trichina. 

Fig.  114. — Eggof  distoma  hepaticum  and  distoma  lanceolatum.    (Heller.) 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS. 


385 


Microscopic  examination  of  the  feces.  Thin,  or  thin-mushy  stools, 
are  examined  without  making  any  addition  to  them.  To  thick,  mushy, 
or  solid  stools,  about  a  half  per  cent,  of  solution  of  salt  is  added  ;  and 
the  solid  portions  must,  of  course,  be  broken  up.    Somewhat  of  a  selec- 


FiG.  115. 


Monads  from  the  feces  (Jaksch).     a,  tricomonas  inlestinalis;  b,  cercomonas  intes. ; 
c,  Amoeba  coli ;  d,  param^secium  coli ;  e,  living  monads ;  /,  dead  monads. 

tion  must  be  made  from  the  different  portions  of  the  stool,  according 
to  the  object  of  the  examination.  In  what  follows  are  presented 
the  details.    The  amplification  also  varies  with  the  object  of  the  exami- 

FiG.   116. 


Microscopical  constituents  of  the  stools  (partly  from  Jaksch  ).  a,  vegetable  fragments ; 
b,  muscular  fibres ;  c,  white  blood-corpuscles ;  d,  saccharomyces ;  e,  microorganisms ; 
y,  crystals  of  triple  phosphate ;  g,  fatty  acid  crystals. 


nation.  In  general,  we  employ  the  dry  method.  When  looking  for 
parasites  (which  have  already  been  described),  it  is  better,  on  the 
other  hand,  to  make  use  of  a  tolerably  strong  amplification. 

25 


386  SPECIAL  DIAGNOSIS. 

1.  Undigested  portions  of  food.  These  may  be  found  in  every 
stool,  and  in  varying  quantities,  according  to  the  kind  of  food  eaten. 
We  mostly  meet  with  coverings  of  vegetable  cells,  elastic  fibres,  etc. 

2.  Portions  of  digested  food.  Although  these,  if  visible  with  the 
naked  eye,  indicate  disturbed  digestion  in  the  small  intestine,  yet 
microscopical  particles  of  these  substances  are  seen  in  small  quantities 
in  normal  stool,  as  well  as  small  portions  of  muscular  fibre,  with  the 
transverse  striations,  shreds  of  connective  tissue,  starch  granules,  and 
fat. 

But  considerable  quantities  of  the  substances  named  always  indicate 
disturbed  digestion  either  in  the  small  intestine  or  the  stomach,  and 
hence  have  the  same  significance  as  the  occurrence  of  larger  pieces, 
which  can  be  seen  without  being  magnified.  When  the  microscopical 
particles  are  colored  a  bright-yellow,  as  we  commonly  see  small  por- 
tions, particularly  of  muscular  tissue,  but  sometimes  almost  all  the 
solid  portions  of  the  stools,  it  shows  that  there  is  unchanged  bile 
in  the  stool,  and  catarrh  of  the  small  intestine. 

Fat,  in  the  shape  of  polygonal  glassy  lumps,  of  needle-shaped 
crystals,  and  also  in  the  form  of  drops,  is  a  very  frequent  constituent 
of  the  stools.  The  glassy  lumps  occur  very  frequently  in  health,  and 
are  often  colored  yellow  or  yellowish-red.  They  are  recognized  as 
fat,  fatty  acids,  or  soap,  by  their  transformation  upon  the  addition  of 
sulphuric  acid,  and,  when  warmed,  into  drops  of  fat  (Mliller).  Drops 
of  fat  occur  in  the  stools  with  milk-diet  (hence,  particularly  in  those 
of  children),  when  taking  cod-liver  oil,  likewise  castor-oil,  and,  if  there 
is  intestinal  catarrh,  then  in  very  considerable  amount. 

The  needles  of  fat  have  pathological  significance.  They  sometimes 
occur  .singly,  and,  again,  in  bundles  and  druses.  They  are  changed 
by  simply  warming  them,  or  by  the  addition  of  acid  and  then  warm- 
ing, into  drops  of  fat,  and  this  takes  place  whether  they  consist  of 
fatty  acids  or  (lime-)  soap. 

When  there  are  great  numbers  of  fat-needles,  it  is  a  pathological 
sign  of  disturbance  of  the  resorption  of  fat,  as  may  result  from 
shutting  oiF  of  the  bile  from  the  intestine,  from  any  form  of  enteritis, 
of  tuberculosis,  amyloid  degeneration  of  the  intestine,  and,  lastly, 
from  disease  of  the  mesenteric  glands. 

The  increase  of  the  fat  in  the  stool  is  not,  as  was  formerly  assumed, 
cbaracteristic  of  a  want  of  pancreatic  juice  (disease  of  the  pancreas, 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS.  387 

closure  of  the  ductus  Wirsungianus).  As  a  matter  of  fact,  the 
absence  of  pancreatic  juice  does  not  seem  to  hinder  the  resorption  of 
fat  (Miiller). 

Detritus.  With  respect  to  detritus  in  the  stools  little  needs  to  be 
said,  because  we  cannot  determine  separately  a  great  number  of  the 
kernels,  husks,  etc. 

3,  Additions  to  the  stools  from  the  alimentary  canal.  A  micro- 
scopical quantity  of  mucus  occurs  in  the  stools  of  persons  in  health. 
Small  glassy  lumps  of  mucus  may  also  be  present,  which  come  from 
the  cells  of  plants.  Usually  the  examination  with  the  naked  eye  is 
sufficient  to  determine  whether  there  is  a  pathological  admixture  of 
mucus. 

It  is  necessary  only  to  mention  that  a  firm  stool,  abundantly  inter- 
spersed with  small  light  lumps  of  mucus,  is  observed  with  intestinal 
catarrh  (Nothnagel).  In  these  cases,  we  can  generally  discover  the 
mucus,  if  we  carefully  examine,  without  any  artificial  aid. 

Epithelium.  Some  cylindrical  cells,  often  in  mucous  metamorpho- 
sis, are  a  frequent  occurrence.  If  the  quantity  is  large,  it  indicates 
intestinal  catarrh.  Very  abundant  cylindrical  epithelium  occurs  in 
chronic  catarrh  of  the  large  intestine,  especially  in  mucous  colic,  in 
this  case  caused  by  mucous  "infarction."  It  has  already  been  men- 
tioned that  regular  shreds  of  mucous  membrane  are  found  in  the 
stools,  also  portions  of  tissue. 

Red  and  white  blood-corpuscles.  These  are  present  in  quantities 
in  fresh  bloody,  and  in  purulent,  stools.  When  seen  but  once,  they 
do  not  have  significance. 

4.  Crystals.  Except  the  fat  crystals  mentioned  above,  there  are 
almost  no  crystals  which  are  brought  into  requisition  for  the  purposes 
of  diagnosis.  Crystals  of  ammoniaco-magnesian  phosphates  (see  these 
under  the  examination  of  the  urine),  no  doubt,  occur  in  the  stools  in 
enteritis  and  abdominal  typhus.  But  they  may  also  be  found  in  any 
other  stools,  if  they  are  not  kept  separate  from  the  urine  and  stand 
for  a  long  time. 

Lime-salts  of  all  kinds,  partly  with  inorganic,  partly  with  organic, 
acids,  in  the  form  of  wedges,  dumb-bells,  needles,  etc.,  sometimes 
colored  an  intense  yellow  by  the  bile  in  the  stool,  have  no  diagnostic 
import. 

Charcot's  crystals,  in   appearance    and  probably  also   chemically 


388  SPECIAL  DIAGNOSIS. 

entirely  agreeing  with  the  Charcot-Leyden  crystals  of  asthma,  are 
observed  in  rare  cases  of  dysentery,  typhus  abdominalis,  intestinal 
tuberculosis,  anchylostomiasis. 

5.  Vegetable  parasites.  We  may  divide  the  large  number  of 
vegetable  microorganisms  which  we  find  in  the  stools,  from  the  stand- 
point of  clinical  diagnosis,  into  two  classes  : 

(a)  Those  which,  primarily,  for  clinical  diagnosis  are  only  of  sub- 
ordinate significance,  because  we  do  not  know  that  they  have  any 
definite  connection  with  any  diseases.  Here,  also,  we  class  those 
which  are  indirectly  harmful — that  is,  they  cause  abnormal  decom- 
position of  the  intestinal  contents.  This  class  is  extremely  numerous, 
and  great  numbers  of  one  kind  or  another  are  present  in  every 
stool.  The  knowledge  of  the  different  kinds  has  recently  been  greatly 
extended  by  the  important  labors  of  Nothnagel,  Bienstock,  Escherich, 
and  others.  But  the  point  has  not  yet  been  reached  which  makes 
them  as  available,  for  clinical  diagnosis,  as  the  other  peculiarities  of 
the  stools.  For  this  reason  we  will  treat  of  them  only  very  briefly 
here. 

Of  the  fungus-spores  we  have  (very  rarely)  that  of  thrush  in 
children  who  are  suffering  from  thrush  in  the  mouth.  Yeast 
fungus,  and,  indeed,  the  different  kinds  of  tortula  cervisiae  (see 
Fig.  116,  c?),  occasionally  occur  in  all  stools,  especially  in  the 
milk-stools  of  children.  In  intestinal  dyspepsia  with  acid  fer- 
mentation they  are  generally  more  abundant  than  in  normal  diges- 
tion. But  the  schizomycetes  belong  to  the  numberless  micro- 
organisms which  are  seen  in  every  microscopical  preparation  of  the 
stools,  whether  normal  or  pathological.  Of  chief  importance  are  the 
micrococci  and  bacilli.  A  very  large  part  of  these  are  colored  yellow 
or  brownish  with  iodine  and  iodide  of  potassium  ;  others  are  colored 
by  the  same  reagent  blue  or  violet  (Nothnagel).  These  latter, 
according  to  Jaksch,  are  increased  in  intestinal  catarrh. 

We  are  already  able  to  conclude  that  the  knowledge  of  these 
intestinal  bacteria  furnish  diagnostic  indications  of  anomalies  in 
intestinal  digestion,  and  that  the  different  kinds  of  bacilli  possess 
extraordinary  biological  peculiarities.  Some  require  for  their  rapid 
development  a  neutral  or  slightly  alkaline  reaction,  while  others  an 
acid  reaction,  of  the  intestinal  contents ;    some  are  aerobiotic,  others- 


EXAMINATION  OF  THE  DIGESTIVE  APPARATUS. 


389 


anaerobiotic  ;  and  while  some  have  the  power  to  transform  starch  into 
sugar,  others  cause  the  decomposition  of  albumin. 

(5)  Pathogenic  fungi.  These  we  are  able  to  isolate,  and  from 
them  diagnosticate  the  disease  they  cause,  as  the  tubercle-bacillus  in 
the  sputum. 

Here,  also,  belong  ih.e pathogenic  schizomycetes.  These  are :  Koch's 
cholera  bacillus,  the  bacilli  of  typhus  and  tubercle. 

Cholera  bacilli  (comma  bacilli)  are  the  pathognomonic  sign  of 
Asiatic  cholera.  They  are  short,  more  or  less  crooked  rods,  which 
are  sometimes  connected  one  to  another  in  such  a  way  as  to  form 
"spirals,"  like  a  screw.  The  curve  may  be  very  slight,  even  want- 
ing: or  marked,  even  semicircular.  In  general,  they  are  shorter, 
but  thicker,  than  the  bacilli  of  tubercle. 


Fig.  117. 


^«%rvvy 


Comma  bacillus,  pure  culture  (prepared 
by  Prof.  Gartner).  Zeiss's  immersion 
lens  one-twelfth,  eye-piece  No.  2,  camera 
lucida.     Magnified  about  600  times. 


-    i  jJVfjil 


Cholera  dejections  upon  a  damp  sheet. 
(Two  days  old. )  a,  S-form  bacilli,  600  :  x. 
(Koch.) 


Sahitat :  mode  of  preparation.  They  are  particularly  found  in 
the  free  mucous  floccules  of  rice-water  stools,  also  very  abundantly 
upon  the  linen  soiled  by  the  dejections,  and,  indeed,  here  after  two 
or  three  days,  provided  the  linen  has  been  kept  moist.  A  mucous 
floccule  (or  a  drop  of  the  stools),  or  some  of  the  deposit  on  the  linen, 
is  placed  upon  a  covering-glass.     First  dry  it  in  the  air,  then  pass  it 


390  SPECIAL  DIAGNOSIS. 

two  or  three  times  through  the  flame  of  a  spirit-lamp,  and  stain  it 
with  methylene-blue  or  fuchsin  by  warming  it  one  to  five  minutes. 

These  bacilli  have  been  found,  we  may  say,  constantly  in  the  stools 
of  Asiatic  cholera  by  a  great  many  other  examiners  besides  Koch, 
and  they  are  found  in  no  other  stools.  They  must,  therefore, 
diagnostically  be  of  pathognomonic  value  to  even  those  who  doubt 
Koch's  teachings  concerning  their  pathogenic  character. 

Fig.  119. 


Covering-glass  preparation  of  a  mucous  floccule  in  Asiatic  cholera.  Zeiss's  homogeneous 
immersion  one-twelfth,  eye-piece  No.  2,  drawn  by  a  camera  lucida.  Magnified  about 
650  diameters. 

But  since  the  morphological  peculiarities  of  the  cholera  bacillus  in 
the  microscopical  preparation  do  not  furnish  an  absolutely  certain 
recognition,  and,  on  the  other  hand,  since  there  is  no  specific  reaction 
(as  with  the  tubercle-bacillus),  in  order  to  determine  an  isolated  case, 
it  is  indispensably  necessary  to  establish  a  pure  culture.  (See, 
regarding  this,  the  works  upon  bacteriology.) 

Comma  bacilli  are  also,  in  individual  cases,  found  in  the  vomit  of 
Asiatic  cholera. 

Morphologically,  but  not  biologically,  they  are  like  Finkler  and 
Prior's  spirals  of  cholera  nostras,  which  possibly  stand  in  the  same 
relation  to  this  latter  disease  that  the  comma  bacillus  does  to  Asiatic 
cholera.  They  are  positively  distinguished  from  the  bacilli  of 
Asiatic  cholera  by  pure  culture. 


EXAMINATION   OF  THE  DIGESTIVE  APPARATUS.  391 

A  bacillus  which  is  morphologically  like  the  comma  bacillus  occurs 
in  tooth-mucus  (Lewis  and  Miller),  and  just  such  an  one,  also,  in  old 
cheese  (cheese-spirals,  Deneke).  Biologically,  they  diiFer  from  Koch's 
comma  bacillus  and  from  each  other. 

Typhus  abdominalis  bacillus.  These  bacilli  are  regularly  found  in 
typhus  abdominalis,  in  the  diseased  portion  of  intestine,  in  the  mesen- 
teric glands,  the  spleen  and  liver,  in  the  kidneys,  and  also  frequently 
in  the  blood  (which  see).  They  have  also  frequently  been  found  in 
Fig.  120.  Fig.  121. 


vse-  -S^-jfpj-^,^''. 


Spirillum  (Finkler  and  Prior),  700  :  1.  Typhus  abdominalis  bacillus  in  pure  cul- 

(Flugge.)  ture.     Zeiss's  homogeneous  immersion  lens 

one-twelfili,  eye-piece  No.  2,  drawn  with 

camera  lucida.    Magnified  about  650  times. 

the  stools  of  typhus.  But  since  they  are  neither  distinguished  by 
their  form  (just  at  the  end  they  are  rounded  ;  are  about  as  long  as 
the  tubercle  bacillus,  but  are  much  thicker — about  one-third  as  thick 
as  long)  nor  by  a  specific  color-reaction  from  the  other  bacilli  which 
occurs  in  the  stools,  their  microscopical  proof  is  extremely  uncertain. 
Pure  cultures  are  here  much  more  necessary  for  the  positive  deter- 
mination, and  even  then  are  uncertain. 

The  typhus  abdominalis  bacillus  is  best  stained  with  methylene- 
blue  or  fuchsine  in  a  dry  preparation  upon  the  glass  cover. 

Tubercle  bacillus.  These  are  frequently  found  in  tuberculous 
ulcers  of  the  intestine.  It  is  not  yet  sufficiently  established  whether 
they  are  always  present,  chiefly  because  not  infrequently  tubercular 
ulcers  of  the  intestines  do  not  have  any  symptoms,  and  particularly 
:  do  not  cause  diarrhoea ;  and  so,  often  enough,  the  firm  stools  are  not 
I  examined  for  bacilli.  On  the  other  hand,  in  phthisical  patients,  the 
tubercle  bacillus  is  sometimes  observed  in  the  stools  without  there 
being  any  intestinal  tuberculosis.  They  come  from  swallowing 
tuberculous  sputum.^ 

1  Amoeba  coli  is  a  protozoa  which  has  been  found  by  Koch,  Osier,  Dock,  and  others 
in  the  stools  of  patients  suffering  from  severe  chronic  enteritis  and  dysentery. — 
Translator. 


CHAPTER    YII. 

EXAMINATION  OF  THE  URINARY  APPARATUS. 

This  comprises  the  examination  of  tlie  urinary  organs  themselves 
and  the  examination  of  the  urine.  Indeed,  in  very  many  eases,  the 
latter  examination  only  is  made,  or  it  forms  the  chief  part,  whether 
in  its  relation  as  being  the  secretion  of  the  kidneys,  or  whether  it  be 
in  reference  to  admixtures  or  alterations  of  the  urine,  which  occur  in 
the  course  of  its  transit  through  the  urinary  passages.  The  local 
examination  of  the  urinary  organs  is  now  not  often  required,  but  if 
it  is,  the  result  of  the  examination  generally  confirms  the  diagnosis. 
This  direct  examination,  therefore,  oui2;ht  never  to  be  neglected 
Moreover,  where  the  kidneys  themselves  are  diseased  there  come  into 
consideration  certain  resulting  phenomena  in  the  different  organs  of 
the  body. 

Examination  of  the  Kidneys. 
Anatomy. 

The  kidneys,  about  10  to  12  cm.  long,  about  5  cm.  broad,  of  well- 
known  form,  lie  upon  the  two  sides  of  the  spinal  column,  upon  the 
anterior  surface  of  the  quadratus  lumborum  muscle  and  the  lumbar 
portion  of  the  diaphragm,  and  reach  from  the  level  of  the  twelfth  dorsal 
vertebra  to  the  level  of  the  second  or  third  lumbar  vertebra.  The 
lower  portions  diverge  somewhat  downward,  and  hence  lie  with  their 
lower  ends  somewhat  further  from  the  median  line  of  the  body  (about 
three  fingers'  breadth)  than  the  upper  ends  (about  two  fingers'  breadth). 
The  right  kidney  is  a  little  lower  down  than  the  left. 

The  upper  half  of  both  kidneys  is  covered  by  the  eleventh  and 
twelfth  ribs,  the  extreme  upper  portion  also  by  the  complementary 
pleural  sinus  (see  Fig.  122);  hence,  the  lower  border  of  the  lungs  does 
not  extend  as  low  down  as  the  kidneys.  It  is  very  important  to  note 
that  the  outer  border  of  both  kidneys  corresponds  tolerably  exactly 
(392) 


EXAMINATION  OF  THE  URINARY  APPARATUS.  393 

-with  the  outer  border  of  the  thick  fleshy  hiyer  of  the  sacro-spinalis 
muscle. 

The  left  kidney  at  its  upper  end,  rather  by  its  suprarenal  capsule, 
is  in  contact  with  the  spleen;  the  right  kidney,  with  the  under  surface 
of  the  liver.  Both  organs  encroach  upon  the  upper  end  of  the  kidney 
of  their  respective  sides,  like  the  tiles  of  a  roof  (see  Fig.  122).  The 
figure  also  furnishes  information  regarding  the  so-called  spleen-kidney 
and  liver-kidney  angle. 

Fig.  122. 


Anatomical  situation  of  the  kidneys.  (Weil.)  a.  d,  borders  of  the  lungs;  c,  e,  limits 
of  the  pleural  sacs;  f,  angle  between  the  spleen  and  kidney;  g,  angle  between  the  liver 
and  kidney. 

The  superior  surface  of  each  kidney  is  covered  by  the  parietal 
peritoneum,  and  in  front  of  it  lies  the  ascending  or  descending  colon. 
The  anterior  inner  border  of  the  right  kidney  is  not  far  from  the 
ductus  choledochus  and  the  duodenum. 

In  the  rare  condition  known  as  horseshoe-kidney,  the  lower  ends  of 


394  SPECIAL  DIAGNOSIS. 

the  two  kidneys  are  connected  by  a  transverse  band  consisting  of 
kidney-parenchyma.  This  transverse  portion  passes,  like  a  bridge, 
across  the  aorta  and  the  spine,  about  on  a  level  with  the  second 
lumbar  vertebra. 

Local  Examination  of  the  Kidneys. 

In  every  respect  its  result  is  almost  negative.  The  normal  kidney, 
of  course,  cannot  be  inspected.  In  remarkably  exceptional  cases 
we  may,  by  employing  bimanual  palpation,  with  the  legs  drawn 
well  up  (one  hand  being  placed  behind  in  the  lumbar  region  and 
the  other  pressing  deeply  in  front),  get  some  information,  provided 
tKe  abdominal  covering  is  very  unusually  lax  and  thin,  and  the 
stomach  is  empty.  Of  late,  percussion  of  the  kidneys  has  very 
rightly  come  more  and  more  into  discredit.  It  must  be  perfectly 
evident  to  every  one  that  it  is  impossible  to  point  out  the  normal 
kidneys,  or  even  moderately  enlarged  ones,  if  he  remembers  that  the 
kidney  is  less  voluminous  than  the  spleen ;  that,  moreover,  it  lies 
much  less  favorably ;  and,  besides,  if  he  takes  into  consideration  how 
often  the  normal  spleen  is  with  difficulty,  or  cannot  at  all,  be  made 
out.  The  kidney  is  unfavorably  located  for  percussion,  because  the 
sacro-spinalis  muscle  (of  considerable  mass)  lies  over  it,  but  especially 
for  the  reason  that  its  lateral  border  almost  exactly  corresponds 
with  the  convex  border  of  the  kidney.  So  we  cannot  with  certainty 
determine  whether  the  kidney  lies  under  the  muscle,  nor  where  its 
limits  are. 

Individual  exceptional  cases,  where  very  thin  or  atrophic  sacro- 
spinalis  muscles  permit  of  percussion  of  the  kidneys,  may  nevertheless 
occur,  as  the  cases  mentioned  above,  where  the  normal  kidneys  can 
be  felt.  But  we  cannot  consider  the  result  of  percussion  of  the 
kidneys  as  of  great  value. 

Pathological  Qonditions  of  the  Kidneys. 

Inspection.  The  kidney  can  only  be  inspected  when  it  is  very 
much  enlarged,  or  enlarged  and  displaced.  Tum.ors  of  the  kidney 
may  make  their  appearance  in  the  lumbar  region,  in  the  side,  and  in 
the  lateral  anterior  portion  of  the  abdomen,  near  the  border  of  the 
ribs.     According  to  their  nature,  they  are  smooth,  roundish,  irregular, 


EXAMINATION  OF  THE  URINARY  APPARATUS.  395 

or  uneven  (see  Palpation).  They  do  not  move  with  respiration.  Their 
appearance  may  strikingly  vary,  but  not  necessarily  so,  with  the 
changes  of  position  of  the  body  (the  dorsal  position,  lying  down).  If 
the  tumor  is  very  large,  then  it  generally  presses  the  colon,  ascending 
or  descending,  toward  the  anterior  abdominal  wall,  and  then  the  colon, 
according  to  the  amount  of  its  distention,  may  lie  up  against  the 
abdominal  wall  (see  Palpation). 

If  the  kidney  is  the  seat  of  a  tumor,  it  very  often  departs  from  its 
place  high  up  against  the  diaphragm,  and  becomes  the  so-called 
wandering  kidney.  In  this  case  it  is  much  easier  seen  from  in  front. 
A  normal  kidney  wandering  so  much  as  to  be  visible,  is  a  curiosity 
(Bartels). 

A  roundish,  symmetrical  swelling,  located  in  the  dorsum  in  the 
region  of  the  kidney,  or  somewhat  sidewise  from  it,  points  to  purulent 
perinephritis.  Sometimes  it  extends  upward  in  the  abdominal  cavity, 
from  the  diaphragm  being  pushed  up.  Often  there  is  oedema  of  the 
skin  at  the  spot  (deep  formation  of  pus,  see  p.  62),  or  there  may  be 
inflammatory  redness.  Moreover,  abscess,  due  to  the  congestion 
accompanying  caries  of  the  spine,  may  break  here.  Also,  large  peri- 
nephritic  abscesses  have  been  seen  as  tumors  above  the  border  of 
Poupart's  ligament  in  the  iliac  region. 

Palpation.  This  is  most  important  in  the  local  examination  of  the 
kidneys.  We  employ  it  in  the  dorsal  position  with  the  knees  well 
drawn  up,  but  sometimes  also  in  the  abdominal  position.  In  both 
cases,  we  always  first  examine  bimanually,  one  hand  being  upon  the 
region  of  the  kidney  and  the  other  upon  the  abdomen. 

Tenderness  upon  pressure  occurs  :  sometimes  in  acute,  almost  never 
in  chronic,  nephritis  ;  also  in  tumor  of  the  kidney,  stone  in  the  pelvis 
of  the  kidney,  in  case  it  excites  inflammation ;  in  inflammatory 
hydronephrosis,  and  in  perinephritis  (here  there  is  often  very  great 
sensibility). 

When  the  kidney  is  enlarged  from  engorgement,  amyloid  disease, 
or  nephritis  (large  white  kidney),  it  is  never  perceptible  to  palpation 
oxcept  it  leave  its  place  (wandering  kidney),  or  we  have  one  of  the 
exceptional  cases  in  which  even  a  kidney  of  normal  size  and  location 
can  be  felt  (see  above.  Local  Examination  of  the  Kidney).  Very 
large  new  formations,  as  carcinoma,  sarcoma,  hydro-  and  pyo-nephro- 
sis,  echinococcus,  and  perinephritis,  only  are  palpable.     The  tumor 


396  SPECIAL  DIAGNOSIS. 

can  be  felt  in  one  side  of  the  lumbar  region,  or  at  one  side  of  the 
anterior  abdominal  region.  With  new  formations  it  is  usually  uneven  ; 
in  hydronephrosis,  smoothly  round,  more  or  less  tense,  under  some 
circumstances  fluctuation  can  be  distinctly  made  out.  Echinococcus 
is  usually  smooth  and  tensely  elastic;  it  may  show  hydatid  vibration 
(see  above,  p.  326). 

It  is  important  to  remember  that  tumor  of  the  kidney  is  only  very 
rarely  movable  upon  pressure  (for  if  it  descends,  then  we  have  a 
wandering  kidney).  We  have  never  seen  a  case  where  one  moved 
with  respiration ;  but  it  seems  that  in  some  cases  there  is  this  move- 
ment. At  any  rate,  the  absence  of  respiratory  movement  points  to 
the  kidney,  and  especially  against  the  spleen  or  a  tumor  fixed  to  the 
liver. 

In  a  considerable  number  of  cases  it  will  be  found  that  the  ascend- 
ing and  descending  colon  is  in  front  of  the  kidney-tumor  and  pressed 
by  it  against  the  abdominal  wall.  In  these  cases,  tliis  fact  has  great 
value  for  differential  diagnosis.  In  other  cases,  the  tumor  will  be 
found  lying  exactly  in  the  median  line,  and  then  it  is  of  significance 
for  differential  diagnosis,  especially  from  ovarian  tumor.  The  location 
of  the  colon,  moreover,  is  usually  only  made  out  with  certainty  Avhen 
it  can  be  felt,  and  particularly  when  it  contains  air.  It  is,  therefore,, 
advisable  to  inflate  it  (see  p.  311). 

Wandering  Mdney ;  movable  hidnei/.  By  this  we  understand- 
downward  dislocation  of  the  kidney,  whether  much  or  little.  Almost 
always  only  one  is  dislocated,  and  this  is  usually  the  right  one.  In 
these  cases  the  kidney  is  commonly  of  normal  size,  but  it  may  be 
enlarged,  and  this  is  most  frequently  due  to  hydronephrosis  caused 
by  the  bending  of  the  ureter,  or  also  because  it  is  the  seat  of  a  new 
formation. 

It  is  generally  very  easy  to  recognize  a  kidney  that  is  very  much 
out  of  place,  but  when  it  is  still  high  up,  near  the  liver  or  the  spleen, 
it  is  often  very  difficult  to  do  so.  The  diagnosis  is  based  upon  the 
bean-shaped  form  of  the  kidney,  eventually,  upon  its  being  of  the 
appropriate  size,  and  upon  its  mobility  by  pressure,  which  is  almost 
never  wanting;  also,  sometimes,  Avith  the  changes  of  position  of  the 
body.  Not  infrequently  the  kidney  can  be  perfectly  replaced.  In 
some  cases  dyspeptic  symptoms,  even  dilatation  of  the  stomach,  also 
jaundice  from  engorgement,  have  been    observed  when    the   right 


EXAMINATION  OF  THE  URINARY  APPARATUS.  397 

kidney  was  displaced  (from  compression  of  the  duodenum  or  of  the 
ductus  choledochus).  Those  cases  are  rarities  where  the  pulse  can  be 
felt  in  the  renal  artery. 

Percussion.  We  employ  percussion  to  establish  the  existence  of 
tumors  of  the  kidney  which  give  a  deadened  sound,  on  account  of  their 
solidity ;  but  they  are  almost  always  clearly  made  out  by  palpation. 
Its  value  in  determining  dislocation  of  the  kidney  was  formerly  very 
much  over-rated.  It  Avas  thought  that  we  were  able  to  prove  one-sided 
dislocation  of  the  kidney,  because,  when  the  patient  was  lying  upon 
the  abdomen,  the  resonance  of  the  two  sides  in  the  neighborhood  of 
the  kidneys  Avas  found  to  be  dilFerent :  clearer  upon  the  side  of  the 
wandering  kidney,  in  contrast  with  the  absolute  dulness  of  the  normal 
side.  In  our  opinion,  even  in  the  most  favorable  cases,  such  a  con- 
dition cannot  be  employed  for  deciding  the  diagnosis. 

But,  on  the  other  hand,  percussion  may  be  of  the  greatest  value, 
either  to  determine  the  relation  of  a  tumor  in  one  side  of  the  abdomen 
to  the  colon,  or  to  determine  the  course  of  the  colon  over  a  tumor  of 
the  kidney  (see  above).  In  such  a  case,  distending  the  colon  Avith  air 
is  of  the  greatest  assistance.  Further,  it  might  possibly  occur  that  a 
considerable  enlargement  of  the  kidney  could  be  made  probable  (never 
certain)  by  an  area  of  dulness  upon  the  back,  extending  from  the  region 
of  the  kidneys  toward  the  side. 

Differential  diagnosis  of  tumor  of  the  kidney.  The  positive  evi- 
dence of  tumor  of  the  kidney  has  just  been  spoken  of.  We  may  have 
to  make  a  differential  diagnosis  between  a  right  kidney  which  is  not 
very  much  displaced  downward  and  a  distended  gall-bladder,  or  an 
echinococcus  located  upon  the  lower  surface  of  the  liver.  If  there  is 
respiratory  mobility,  this  speaks  against  it  being  the  kidney,  but  if 
the  tumor  can  be  replaced,  so  that  it  may  even  disappear,  then  it 
speaks  for  it  being  the  kidney.  Both  wandering  kidney  and  a  pe- 
dunculated echinococcus  may  be  easily  movable  upon  pressure.  It 
may  often  be  impossible  to  determine  exactly  the  form  of  a  tumor 
situated  close  under  the  liver. 

A  wandering  left  kidney  is  distinguished  from  a  wandering 
spleen  by  the  form,  which  is  made  out  by  percussing  the  neighbor- 
hood of  the  region  of  the  spleen  :  in  wandering  spleen,  we  may  find 
notches  ;  if  it  is  the  kidney,  Ave  may  feel  the  pulse  at  the  hilus.  We 
distmguish  tumor  of  the  left  kidney  from  tumor  of  the  spleen  by  the 


398  SPECIAL  DIAGNOSIS. 

form  and  relation  to  the  colon.  Sometimes  respiratory  mobility 
decides  in  favor  of  the  spleen ;  but  with  this  it  may  also  be  wanting ; 
while  notches  on  the  upper  border  of  the  tumor  may  speak  with  prob- 
ability for  the  spleen,  yet  in  one  case,  where  they  could  be  very  dis- 
tinctly felt,  they  led  us  to  a  false  diagnosis ;  it  was  found  to  be  a 
carcinoma  of  the  kidney. 

We  know  of  one  case  where  a  movable  tumor  of  the  left  side  of 
the  abdomen  was,  by  a  recognized  master  of  percussion,  pronounced  a 
wandering  kidney  on  account  of  the  tympanitic  resonance  in  the 
region  of  the  left  kidney.  It  was  operated  upon  ;  it  proved  to  be  a 
Avandering  spleen.  It  was  extirpated  with  permanently  favorable 
result. 

Examination  op  the  Ureters  and  Bladder. 

Simon,  by  introducing  the  hand  into  the  rectum,  has  repeatedly 
felt  of  the  ureters  (see  works  upon  Surgery).  Recently  Heger- 
Kaltenbach  and  Sanger  have  proposed,  in  the  case  of  women,  to  palpate 
them  jjer  vaginam.  We  can  feel  their  lower  ends  where  they  come 
down  on  either  side  of  the  neck  of  the  uterus  and  enter  the  lower  side 
of  the  bladder.  With  some  practice  often  even  a  normal  ureter,  but 
still  more  one  that  is  thickened,  can  be  felt  in  the  lateral  and  anterior 
fornix  vagince  and  the  anterior  vaginal  wall  close  to  the  middle  line. 

In  this  way  it  is  not  difficult  to  recognize  thickening  or  tenderness 
of  one  or  both  ureters.  Both  occur  in  cystopyelitis  and  in  tubercu- 
losis of  the  urinary  apparatus ;  thickening  and  distention  may  some- 
times be  observed  also  in  pyelitis  calculosa  (renal  calculus). 

The  bladder  lies  behind  the  symphysis  pubis,  when  ordinarily  dis- 
tended, it  rises  above  it,  but  only  when  it  is  excessively  full,  as  in 
paralysis  of  the  bladder,  spasm  of  the  sphincter,  stone  in  the  bladder,, 
stricture  of  the  urethra,  does  it  swell  so  much  as  to  be  noticed  (rarely) 
by  inspection;  but  especially  by  palpation  and  percussion,  as  a 
roundish  tumor,  which,  of  course,  is  dull  in  sound.  In  men  it  can 
also  be  felt  from  the  rectum.  We  are  able  to  decide  with  certainty 
whether  a  tumor  in  the  hypogastrium  is  a  distended  bladder  or  not 
by  drawing  off  the  urine  with  a  catheter.  It  may  be  confounded 
with  a  pregnant  uterus,  and  also  with  other  swellings.  Always  before 
undertaking  an  examination  of  the  abdomen,  we  must  see  that  the 
bladder  is  empty,  partly  to  avoid  confounding  the  distended  bladder 


EXAMINATION  OF  THE  URINARY  APPARATUS.  399 

with  something  else,  and  partly  because,  if  the  bladder  is  full,  it  inter- 
feres with  the  examination  of  the  abdomen. 

Anomalies  located  in  the  wall  of  the  bladder  can  usually  be  felt 
best  when  the  bladder  is  full.  The  external  examination  is  made  |:>er 
var/incon,  per  rectum,  and  sometimes  bimanually. 

Surgery  and  gynecology  teach  the  complicated  methods  of  examining 
the  bladder  and  ureters.  With  reference  to  the  examination  of  the 
male  urethra,  we  refer  to  works  upon  Surgery. 

Examination  of  the  Ukine. 

Under  normal  conditions  and  when  free  from  admixture,  the  urine,  as 
it  issues  from  the  orifice  of  the  urethra,  exhibit?  the  renal  secretion  in 
a  state  of  purity,  since,  in  its  transit  through  the  urinary  passages,  it 
receives  scarcely  any  additions  from  the  mucous  membrane  that  are 
worth  mentioning ;  and  further,  since,  at  the  time  of  its  discharge 
from  the  body,  and  for  some  time  after,  its  physical  and  chemical 
conditions  are  the  same  as  at  the  moment  of  secretion.  In  a  number 
of  pathological  conditions,  also,  the  urine  is  the  pure  and  unaltered 
secretion  of  the  kidneys ;  while,  in  a  second  series  of  diseases,  it  is 
changed  by  its  exit  from  the  body,  and,  indeed,  by  admixtures  from 
the  urinary  passages,  or  by  decomposition  of  its  constituents  in  the 
bladder.  To  the  first  series  belong  the  anomalies  of  the  secretion 
itself;  to  the  second,  the  diseases  of  the  urinary  passages. 

In  women  the  urine  may  be  contaminated  by  admixture  of  material 
from  the  vagina  or  uterus,  and  of  these  the  most  frequent  and  impor- 
tant is  the  menstrual  fluid.  In  order  to  avoid  this  contamination,  we 
are  sometimes  obliged  to  draw  off  the  urine  with  the  catheter.  It  is 
usually  contaminated  by  fecal  material  only  from  carelessness  of  the 
patient  or  of  the  attendant.  But  sometimes  it  results  from  commu- 
nication of  the  intestine  with  the  urinary  passages,  as  of  the  rectum 
with  the  bladder  or  with  the  vagina. 

Recent  investigations  by  Lustgarten  and  Mannaberg  show  that  the 
former  assumption  that  the  urine  is  normally  free  from  bacteria  must 
be  given  up.  The  urine  of  healthy  persons  contains  a  number  of 
microorganisms  which  have  their  origin  in  the  urethra.  The  most 
important  are  a  large  streptococcus,  a  diplococcus  which  resembles  the 
gonococcus,  also  like  that  in  epithelium,  but,  of  course,  it  is  not  found 


400  SPECIAL  DIAGNOSIS. 

in  pus-corpuscles,  and  lastly,  a  bacillus  which  morphologically  and  in 
its  color- reactions  agrees  with  the  tubercle  bacillus,  and  which  probably 
is  the  smegma  bacillus,  which  also  occurs  in  the  preputial  sac.  This 
latter  may  give  occasion  for  the  erroneous  supposition  that  there  is 
tuberculosis.  But  that  it  has  its  origin  in  the  urethra  is  shown  by  the 
fact  that  it  is  observed  even  when  the  preputial  sac  has  been  most 
carefully  cleaned  previous  to  urination,  though  it  is  only  found  in 
individual  cases,  while  in  cases  of  tuberculosis  it  is  always  abundantly 
found  iu  the  urine.  Sometimes  inoculation  must  decide  (see  Appen- 
dix). We  may  avoid  the  urethral  bacillus  by  drawing  the  urine  with 
a  catheter,  but  then  also,  sometimes,  possible  tubercle  bacilli  from  the 
prostate  or  genital  apparatus  may  be  found  in  the  urine. 

In  case  of  disease  of  one  kidney  or  pelvis  of  the  kidney,  the  question 
may  arise  as  to  what  part  of  the  urine  passed  is  from  the  right,  and 
what  from  the  left,  kidney.  If  one  kidney  fails,  the  other  acts  vicari- 
ously. In  tuberculosis  of  the  urinary  passage  and  in  pyelitis,  it  may 
happen  that  for  a  time  one  ureter  is  stopped ;  the  urine  comes  only 
from  the  other  kidney,  and  it  may  be  quite  normal.  Then,  suddenly, 
the  character  of  the  urine  will  change,  showing  considerable  white 
blood-corpuscles,  seed-like  particles,  tubercle  bacilli,  or  calculi,  and 
blood.  The  quantity  of  urine  is,  for  the  time  being,  increased ;  for 
the  closed  side  has  again  opened. 

In  certain  diseases  of  the  urinary  apparatus,  the  manner  of  passing  the 
urine  shows  characteristic  peculiarities  ;  but  in  many  of  the  conditions 
under  consideration,  the  urine  is  passed  in  a  perfectly  normal  way. 
Painful  strangury,  frequent  urination,  a  feeling  of  burning  in  the 
urethra  while  passing  the  urine,  may  result  from  the  urine  being 
much  concentrated,  such  as  is  passed  when  there  is  engorgement  of 
the  kidneys,  and  in  the  majority  of  cases  of  acute  nephritis.  Very 
pronounced  tenesmus  of  the  bladder — that  is,  painful  urgency,  ex- 
tremely frequent,  very  painful  urination,  in  which  only  a  small 
quantity  of  urine  is  passed  at  a  time — indicates  cystitis.  We  must 
mention  here,  further,  retention  and  incontinence  of  urine,  nocturnal 
enuresis  (regarding  these,  see  under  Examination  of  the  Nervous 
System). 

In  regard  to  the  mode  of  procedure  in  examining  the  urine,  let  it 
be  here  remarked,  in  the  first  place,  that  we  should  take  care  that  the 
urine  is  received  in  vessels  that  are  perfectly  clean — if  possible,  in 


EXAMINATION  OF  THE  URINARY  APPARATUS.  401 

glass  vessels ;  and,  also,  that  forjudging  of  certain  general  character- 
istics, it  is  necessary  to  examine  the  mixed  urine  passed  during 
twenty-four  hours,  or  that  passed  during  the  day  and  during  the 
night,  separately.  For  certain  examinations  it  is  necessary  to  separate, 
in  the  most  careful  way,  the  urine  passed  each  twenty-four  hours.  In 
the  warm  season  of  the  year,  the  urine  ought  to  be  examined  as  soon 
as  possible  after  it  is  passed.  In  order  to  examine  the  sediment,  the 
upper  portion  of  the  urine  is  to  be  carefully  poured  off,  and  the  re- 
maining cloudy  portion  is  put  into  a  conical  glass,  in  which  it  is 
allowed  to  stand  till  the  sediment  is  deposited  ;  then  we  take  up  a  few 
drops  from  the  bottom  of  the  glass  with  a  pipette. 

When  there  is  unconsciousness  or  difficulty  in  passing  the  urine, 
we  must  employ  the  catheter.  The  artificial  emptying  of  the  bladder, 
for  the  purposes  of  examination,  must  never  be  omitted  in  any  case  of 
unconsciousness.  We  briefly  describe  the  characteristics  of  the  normal 
urine. 

(A)  Normal  Urine. 

1.  Amount.  In  twenty-four  hours,  with  healthy  persons,  it  amounts 
on  the  average  to  about  1500  grms.  But  its  variations  within  physi- 
ological limits  are  very  considerable,  since  every  increase  in  the 
amount  of  water  taken  increases  the  amount  of  the  urine,  and  every 
increase  in  the  amount  of  water  disposed  of  in  other  ways  diminishes 
the  urine.  In  the  latter  respect,  in  health  we  have  to  consider  the 
loss  of  water  by  respiration  and  by  perspiration,  from  heat  and  from 
active  bodily  exertion.  It  is  superfluous  in  the  cases  just  referred 
to  to  specify  the  maximal  and  minimal  figures  for  the  amount  of  the 
urine;  only  when  those  conditions  are  wanting,  must  a  departure 
from  the  average  quantity  of  urine  given  above  cause  us  to  think 
of  a  pathological  condition. 

Within  the  twenty-four  hours,  the  least  urine  is  passed  at  night,  or 
in  the  early  morning,  very  much  the  greater  portion  being  passed 
during  the  course  of  the  day.  Usually,  the  amount  of  urine  passed 
increases  about  an  hour  after  taking  fluid.  Emotional  excitement, 
especially  anxiety,  sometimes  temporarily  increases  the  secretion  of 
urine. 

2.  Color  ;  transparency.  In  health,  the  color  is  usually  dark  straw- 
color  to  reddish-yellow.     Generally,  the  greater  the  amount  of  urine 

26 


402  SPECIAL  DIAGNOSIS. 

the  clearer  it  is.  In  this  respect  as  well  as  in  the  quantity,  with 
physiologically  exceptional  cases,  it  shows  marked  variations  from  the 
average ;  from  being  almost  as  clear  as  water,  after  a  great  amount  of 
fluid  has  been  drunk,  to  a  decidedly  dark  reddish-yellow  (concentrated 
urine),  after  severe  sweating.  The  coloring-materials  which  give  the 
normal  color  to  the  urine  are  not  yet  all  exactly  known.  The  most 
important  pigment  seems  to  be  urobilin ;  moreover,  indican  interests 
the  clinician.  Both  coloring-materials  may,  in  disease,  be  pathologi- 
cally increased.     (See  Pathological  Colors  of  the  Urine.) 

Urine  freshly  passed  is,  in  health,  always  perfectly  clear  and 
transparent ;  but  in  these  respects  it  may  change  some  time  after  it 
has  been  passed. 

(a)  In  almost  all  normal  urine,  after  standing  a  short  time,  there  is 
formed  a  slight  cloud  of  mucus.  This  is  from  the  urinary  passages, 
chiefly  from  the  bladder. 

{h)  It  not  infrequently  happens,  with  healthy  persons,  that  the 
urine,  if  somewhat  concentrated,  is  cloudy  when  it  becomes  cool  from 
the  separation  of  the  uric-acid  salts.  Gradually,  the  salts  sink  down 
and  form  a  sediment  of  clear  brick-dust  red  or  flesh- color  (associated 
coloring-matter  of  the  urine,  brick-dust  sediment,  lateritious  sedi- 
ment). It  has  the  pecrdiarity — by  which  it  is  likewise  recognized — 
that  it  is  again  immediately  dissolved  as  soon  as  the  urine  is  warmed. 
After  a  long  march  in  the  heat,  this  sediment  occurs  very  regularly, 
because  the  urine  is  then  concentrated ;  but  it  also  is  observed  in 
urine  that  is  not  so  very  dark,  if  it  is  allowed  to  stand  in  a  cool  place. 
(See  further  regarding  the  Urinary  Sediments,  p.  428.) 

(c)  Urine  that  stands  exposed  for  a  long  time,  both  clear  and  dark, 
likewise  sometimes  becomes  cloudy,  because  it  undergoes  ammoniacal 
fermentation.  The  urea  is  changed  into  carbonate  of  ammonia, 
which  makes  the  urine  alkaline,  whence  there  is  a  deposit  of  phos- 
phates (ammonio-magnesian  phosphates  or  triple-phosphates,  also 
phosphate  of  lime).  Urate  of  ammonia  also  is  formed  and  deposited. 
These  separations  and  numerous  bacteria  render  the  urine  cloudy  and 
gradually  form  a  whitish  sediment.  In  hot  weather  this  ammoniacal 
fermentation  takes  place  within  a  few  hours  after  the  urine  is  passed ; 
in  a  cool  place,  it  does  not  begin  before  36  to  48  hours,  or  not  at  all. 
For  a  more  particular  account  of  the  condition  when  there  is  ammo- 
niacal fermentation  of  the  urine,  see  p.  413. 


EXAMINATION  OF  THE  miNARV  APPARATUS.  403 

3.  Specific  gravity.  In  health  it  usually  varies  between  1015  and 
1020.  It  depends  upon  the  amount  of  solids  held  in  solution  by  the 
urine,  hence,  on  the  one  hand,  upon  the  absolute  quantity  of  the 
solids,  and,  on  the  other,  of  the  amount  of  the  watery  portion  of  the 
urine,  or  the  quantity  of  the  urine.  The  abundant  urine  which 
follows  drinking  a  great  amount  of  water  is  always  of  low  specific 
gravity,  and,  therefore,  clear.  A  scanty  urine,  from  the  loss  of  water 
in  other  ways,  is  always  of  high  specific  gravity,  and  hence  is  dark. 
Then,  also,  in  health  the  specific  gravity,  under  some  circumstances, 
temporarily  oversteps  very  considerably  the  figures  given  above,  from 
as  low  as  1008  to  as  high  as  1025,  or  even  higher.  In  the  absence 
of  "physiological  causes,"  these  figures  are  always  of  pathological 
significance. 

Mode  of  procedure  :  We  measure  the  specific  gravity  of  the  urine 
by  means  of  an  areometer  graduated  for  taking  the  specific  gravity  of 
tlie  urine  (that  is,  from  1000  to  about  1040,  "  urometer").  We  take 
a  portion  of  the  urine  which  we  wish  to  weigh  (generally  a  mixture 
of  that  which  has  been  passed  during  the  previous  twenty-four  hours) 
and  pour  it  into  a  not  too  narrow  cylindrical  glass  until  the  column 
of  urine  is  longer  than  the  urometer.  With  filter-paper  or  a  pipette, 
we  remove  any  air-bubbles  from  the  surface,  and  then  introduce  into 
it  a  perfectly  clean  and  dry  urometer;  wait  until  it  has  become  quiet, 
and  then  observe  the  figure  that  stands  opposite  the  lower  border  of 
the  meniscus  of  the  fluid. 

None  of  the  simple  medical  instruments  is  so  often  useless  as  the 
urometer.  We  shouM  never  use  one  until  its  accuracy  has  been 
tested.  It  is  always  desirable  to  have  a  urometer  upon  which  is  given 
the  temperature  for  which  its  scale  is  arranged ;  not  that  we  must 
always  have  the  urine  at  this  temperature,  but  because  the  absence  of 
this  declaration  from  the  instrument  shows  very  certainly  that  it  has 
been  prepared  without  care. 

4.  Reaction :  In  general,  this  is  always  acid,  chiefly  from  the 
presence  of  acid  urates  and  phosphates,  The  degree  of  acidity  varies 
individually ;  moreover,  it  is  a  constant  quantity  in  every  individual 
case  of  health,  and  when  the  food  is  approximately  alike. 

But  in  the  twenty-four  hours  the  reaction  varies  considerably,  so 
as  to  be  even  alkaline,  and  yet  physiological.  The  variations  proceed 
in  such  a  way  that,  after  every  meal  consisting  of  a  mixed  diet,  the 


404  SPECIAL  DIAGNOSIS. 

acidity  declines  until,  after  about  two  hours,  it  becomes  alkalescent — 
but  this  quickly  passes  so  as  to  give  place  again  to  an  acid  reaction 
(Gorges).  These  variations  have  been  referred  by  many  to  the  loss 
by  the  body  of  acids  and  alkalies  in  stomach  and  intestinal  digestion. 
Hence  it  is  assumed  that  the  separation  of  HCl  in  the  stomach  in- 
creases the  alkalescence  of  the  blood,  and  hence  the  urine  becomes 
less  acid,  or  alkaline.  But,  according  to  recent  investigations  by 
Xoorden,  this  increased  alkalinity  of  the  blood  does  not  exist.  By  a 
graphic  representation  of  the  reaction  of  the  urine  during  twenty-four 
hours  we  obtain  the  so-called  "  acid-curve."  This,  Avith  some  healthy 
persons,  and  under  like  conditions  (as  to  time  and  quality  of  food),  is 
tolerably  constant,  but  with  other  healthy  persons  it  varies  consider- 
ably. 

Sometimes  the  reaction  of  the  urine  is  amphoteric — that  is,  it  colors 
red  litmus  blue,  and  at  the  same  time  colors  blue  litmus  red. 

The  neutral  or  alkaline  urine  of  health  at  the  time  of  passing  is 
usually  clear.  But  it  quickly  becomes  cloudy  from  the  withdrawal 
of  the  phosphates,  which  gradually  form  a  sediment.  The  cloudiness 
does  not  disappear  upon  the  application  of  heat,  but  becomes  more 
marked ;  on  the  other  hand,  the  urine  again  becomes  clear  upon 
adding  acetic  acid,  which  dissolves  the  phosphates. 

5.  Odor.  The  normal  aromatic  odor  of  urine  is  well  known ;  it  is 
changed  by  certain  foods.  Most  frequent  and  most  striking  is  the 
stench  of  urine  after  eating  asparagus ;  garlic  gives  its  odor  to  the 
urine.  During  alkaline  fermentation  we  may  have  the  development 
of  ammonia,  which  gives  its  known  pungent  odor. 

6.  Sediments.  With  reference  to  the  cloudiness,  the  urate  sediment 
of  the  acid,  and  the  phosphatic  sediment  of  the  alkaline  urine,  have 
been  mentioned  on  p.  402.  (Regarding  the  microscopical  condition 
of  the  sediment,  see  p.  430.) 

Whenever  there  is  a  sediment  it  is  not  unimportant  to  remember 
that  different  things  may  have  been  mixed  with  the  urine  after  it  was 
passed  ;  see  above,  p.  390. 

7.  The  portions  in  solution.  The  constituents  of  normal  urine, 
which,  from  our  present  knowledge,  are  of  importance  to  the  clinician, 
besides  the  coloring  materials,  are  the  following :  urea,  uric  acid, 
kreatinin,  oxalic  acid,  chloride  of  sodium,  sulphates,  phosphates, 
carbonates. 


EXAMINATION  OF  THE  URINARV  APPARATUS.  405 


Urea  ■{  COmu^  >  passed    in    tweuty-four    hours    amounts   in   the 


'2 

adult  to  about  30  grammes  (men  somewhat  more,  women  somewhat 
less).  However,  the  amount  of  urea  varies  within  wide  limits :  it  is 
dependent  upon  the  amount  of  albuminous  material  in  the  food  taken, 
and,  on  the  other  hand,  it  is  almost  independent  of  the  amount  of 
muscular  exertion. 

Uric  acid,  like  urea,  is  a  product  of  the  metabolism  of  albu- 
min ;  in  man  the  quantity  is  much  smaller  than  the  former,  being 
in  proportion  to  the  urea  about  as  1  :  45  ;  but  it  is  to  be  remarked  that 
great  variations  take  place,  chiefly  under  the  influence  of  the  food  ; 
and  this  in  such  away  that  albuminous  food  increases  the  acidity  of 
the  urine.  With  reference  to  clinical  diagnosis,  the  uric  acid  as 
well  as  the  kreatinin  is  chiefly  of  interest,  because  they  may  place 
difficulties  in  the  way  in  examining  the  urine  for  sugar,  in  that  they 
sometimes  simulate  the  reaction  of  sugar.  Sometimes,  on  the  other 
hand,  they  hinder  the  reaction  of  sugar  (see  under  Sugar  in  Urine). 

Qhloride  of  sodium,  the  most  important  of  the  inorganic  con- 
stituents, in  health  corresponds  in  amount  with  tolerable  exactness  to 
the  amount  of  salt  in  the  food  taken.  On  the  average,  it  usually  is 
proportioned  to  the  urea  as  1  :  2  to  1 :  3. 

Exceptionally,  in  health,  there  is  found  in  the  urine : 

Albumin,  the  so-called  physiological  albumin.  There  is  still  great 
difference  of  opinion  regarding  this  subject;  while  it  is  doubted  by 
some,  others  maintain  (Senator,  recently  Posner)  that  traces  of  albu- 
min exist  in  the  urine  in  every  healthy  person.  It  occurs  in  very 
small  quantity  (about  one  per  cent.)  after  severe  exertion  or  hearty 
eating.  The  urine  of  the  newly-born  not  infrequently  contains  some 
albumin. 

Sugar  (grape  sugar)  is  observed  in  individual  cases  in  very  small 
quantities.  After  partaking  freely  of  cane  sugar,  this  may  appear  in 
the  urine. 

Bile  acids  are  likewise  observed  in  very  small  quantities  in  normal 
urine. 

Fat  is  recognizable  generally  only  in  microscopical  drops  (or  only 
in  ether  extract),  and  is  found  when  the  food  has  contained  a  great 
abundance  of  fat,  as  of  cod- liver  oil. 


406  SPECIAL  DIAGNOSIS. 

(B)  Pathological  Urine. 
Anomalies  in  the   Quantity. 

Increased  amount  (polyuria)  is  observed. 

1.  In  a  watery  condition  of  the  blood,  in  the  different  forms  of 
anaemia  or  hydrsemia.  The  increase  here  is  never  very  great:  2000 
grammes  or  less ;  there  may  be  no  increase,  and  if  the  heart  is  weak 
(see  below)  it  may  even  be  diminished. 

2.  In  the  different  forms  of  contracted  kidney,  and  this  in  conse- 
quence of  the  accompanying  hypertrophy  of  the  left  ventricle,  which 
causes  increased  pressure  in  the  whole  arterial  system,  and  thus  also 
in  the  renal  arteries  (here  even  to  3500  grammes  or  more).  Here  the 
chief  cause  of  the  polyuria  is  the  increased  arterial  pressure  from  the 
increased  action  of  the  heart  (see  below). 

3.  When  the  exudation  or  transudation  in  the  serous  cavities  of  the 
body,  or  the  fluid  in  the  cellular  tissues  (oedema),  is  resorbed,  the  daily 
excretion  of  urine  sometimes  amounts  to  four  thousand  grams  or  more. 
The  increased  arterial  pressure  from  quickening  of  the  action  of  the 
heart,  which  occurs  at  the  same  time,  is  also  a  prominent  factor  in 
producing  polyuria. 

4.  In  diabetes.  Both  diabetes  insipidus  and  mellitus  (mellituria) 
manifest  themselves  by  the  increase,  often  an  enormous  amount  of 
urine:  4000  to  10,000  grammes,  and  more.  Sometimes  in  diabetes 
mellitus  there  is  only  a  moderate  polyuria,  or,  for  a  time,  in  this  dis- 
ease there  is  even  complete  absence  of  polyuria  (diabetes  decipiens). 
(See  under  Specific  Gravity  and  Sugar  in  the  Urine.) 

5.  As  a  necessary  consequence  of  abnormal  thirst,  polydipsia,  as  it 
is  sometimes  particularly  observed  in  hysteria. 

In  this  connection  we  must  further  mention  the  quite  temporary 
polyuria  which  sometimes  occurs  in  nervous  persons  after  great  mental 
excitement.  -  Finally,  there  is  the  polyuria  which  occupies  a  place  by 
itself,  resulting  from  an  obstruction  somewhere  in  the  urinary  pas- 
sages, where  the  urine  is  held  back,  and  then  the  passage  again 
becomes  free  (see  under  Obstruction). 

Finally,  we  must  briefly  refer  to  some  drinks  which  temporarily 
increase  the  amount  of  the  urine,  as  coffee,  beer,  and  wine,  which 
increase  the  quantity  of  urine  more  than  the  amount  of  water  repre- 
sented. Likewise  there  are  to  be  mentioned  certain  articles  of  diet 
which  have  the  same  effect,  partly  in   that   they  increase  the  blood- 


EX  A  MINA  TION  OF  THE  URINA  RY  A  PPA  RA  TVS.  407 

pressure  by  affecting  the  action  of  the  heart,  partly  in  that  they  stim- 
ulate the  secreting  action  of  the  kidneys. 

In  the  above  pathological  conditions,  where  we  do  not  have  a 
removal  from  the  organism  of  water  that  has  accumulated  there,  then 
the  polyuria  must  be  made  up,  of  course,  by  imbibing  an  increased 
amount  of  drink  (polydipsia).  Whether  we  have  the  increased  thirst 
from  increased  loss  of  water,  or  whether  the  polyuria  is  the  result  of 
the  polydipsia,  is  not  entirely  clear,  especially  in  many  cases  of  dia- 
betes insipidus.  In  diabetes  mellitus  the  polyuria  is  probably  only  a 
purely  secondary  result  of  the  polydipsia,  which,  in  turn,  is  to  be 
regarded  as  the  consequence  of  the  gluktemia  (Cohnheim), 

Diminution  in  the  amount  of  urine,  under  some  circumstances  even 
to  the  extent  of  not  passing  any  (anuria),  occurs  : 

From  diminution  in  the  secretion  of  urine  : 

1.  In  the  loss  of  water  in  other  ways :  in  severe  sweating  (see, 
also.  Normal  Urine) ;  in  any  kind  of  severe  diarrhoea,  particularly  in 
Asiatic  cholera,  where  for  days  together  there  is  continuous  anuria. 
Thus,  also,  during  the  formation  of  a  pleuritic  or  peritoneal  exuda- 
tion, where  fever  is  to  be  taken  into  account  as  a  cause  (see  below). 

2.  In  fever,  and  largely  in  consequence  of  the  loss  of  water  in 
other  ways ;  by  increased  perspiration  and  the  greater  loss  of  water 
by  the  lungs. 

3.  By  reduced  blood- pressure  resulting  from  the  diminished  work 
of  the  heart ;  hence,  in  diseases  of  the  heart-muscle  :  incompensation 
in  valvular  disease,  in  weakening  of  the  hypertrophic  heart  of  con- 
tracted kidney,  in  emphysema,  in  all  the  diseases,  frequently  men- 
tioned, which  harmfully  affect  the  action  of  the  heart.  In  these 
conditions  the  amount  of  the  urine  is  the  chief  means  of  forming  a 
judgment  of  the  course  of  the  disease,  and  furnishes  the  indications 
for  treatment. 

4.  In  acute  nephritis,  subacute  and  chronic  nephritis,  except  con- 
tracted kidney  (regarding  which  see  also  under  3).  In  these  diseases, 
also,  the  amount  of  the  urine  is  a  symptom  which  indicates  the 
severity  of  the  case.  In  acute  nephritis  there  not  infrequently  is,  for 
a  time,  anuria. 

5.  From  suppression  of  urinary  secretion  due  to  nervous  causes, 
especially  in  a  still  indistinct  reflex  way  in  trauma,  as  from  operations 
affecting  the  abdomen. 

Also,  there  may  be  a  less  quantity  of  urine  from  difficulty  in  mic- 


408  SPECIAL  DIAGNOSIS. 

turition  ;  from  a  very  narrow  stricture  of  the  urethra  (surgery)  ;  from 
retention  in  the  bladder;  from  obstruction  in  the  ureters.  In  regard 
to  the  latter,  when  one  kidney  is  cut  oif,  the  other  generally  vicari- 
ously performs  the  work  of  both ;  but  there  may  also  be  anuria  when 
one  ureter  is  closed,  as  from  stone  in  the  kidney,  and  this,  in  fact, 
from  a  kind  of  reflex  suppression  in  the  other  kidney  (see  Shock). 

The  great  zeal  in  using  the  catheter  in  recent  times  has  given  us 
as  a  result,  among  other  things,  the  knowledge  of  the  fact  that  in 
health  with  every  urination  the  bladder  is  completely  emptied,  even 
to  a  few  drops.  If  a  certain  amount  of  urine  remains  in  the  bladder 
(residual  urine)  there  is  a  pathological  cause  for  it.  This  may  be  a 
purely  mechanical  hindrance  to  the  emptying  of  the  bladder,  as 
stricture,  hypertrophy  of  the  prostate,  urinary  calculi ;  or  it  may 
result  from  the  mechanical  hindrance,  atony  of  the  bladder ;  or  there 
may  be  primary  nervous  paresis  of  the  detrusor,  as  occurs  in  tabes 
and  in  all  diseases  of  the  lumbar  cord.  The  amount  of  residual  urine 
is  said  to  be  tolerably  constant ;  it  is  measured  by  having  the  patient 
pass  his  urine,  and  then  use  the  catheter  immediately  afterward. 
Color  and  Transparency  of  the   Urine  in  Disease. 

Primarily,  the  color  varies  according  to  the  degree  of  concentration, 
in  the  same  way  as  in  normal  urine;  and  as  in  health,  so  also  in 
general  in  disease,  it  stands  in  a  certain  relation  to  the  amount  of  the 
urine :  the  greater  the  amount  the  clearer  the  urine.  But,  like  the 
variations  of  quantity  from  the  average,  the  changes  in  the  color  of 
the  urine  are  also  much  more  significant  in  disease  than  is  the  case 
in  normal  urine.  The  scale  of  colors  of  the  urine  passes  from  the 
almost  colorless  to  the  straw-yellow,  reddish,  red-brown,  even  brown- 
black.  It  is  not  necessary  to  have  a  very  exact  determination  of  the 
color  of.  the  urine  by  comparing  it  with  those  of  a  table  of  colors,  as 
was  proposed  by  Vogel,  because  it  could  only  have  a  value  in  deter- 
mining the  degree  of  concentration,  and  generally  for  this  the  specific 
gravity  is  much  more  exact  (see). 

Patients  with  cirrhosis  (without  icterus,  which  see)  sometimes  pass 
urine  that,  in  proportion  to  its  amount,  is  very  dark.  Anaemic  (chlo- 
rotic)  persons,  on  the  other  hand,  often  pass  remarkably  clear  urine. 

In  fever  the  urine  is  relatively  dark — reddish  or  brownish-red  (see 
below,  IJrobilin, 


EX  A  MINA  TION  OF  THE  URINA  R  Y  A  PPA  RA  TVS.  409 

In  diabetes  melUtus  there  is  a  peculiai'ity  in  the  very  striking  con- 
tradiction between  the  clear  color  and  great  amount  of  the  urine  on 
the  one  side,  and  its  high  specific  gravity  upon  the  other,  which  is  of 
diagnostic  importance. 

As  special  pigments  of  the  urine,  the  following  are  to  be  men- 
tioned : 

1.  Color  due  to  the  increase  in  the  normal  pigments.  Two  of  these 
come  into  consideration  herfe  : 

Indiean.,  occurring  in  increased  amount  may  sometimes  give  to  the 
urine  a  bluish  or  bluish-black  color,  if  it  has  been  decomposed  in  the 
urinary  passages  and  changed  into  indigo-blne  ;  but  very  often  we  do  . 
not  recognize  that  the  urine  contains  more  indican,  because  indigo 
has  not  yet  been  formed.  Hence,  when  there  is  a  suspicion  of 
indican,  or  if  we  wish  to  make  use  of  its  possible  presence  for  the 
purposes  of  diagnosis,  even  when  the  urine  appears  to  be  perfectly 
normal,  we  must  examine  it  with  reference  to  this  substance.  When 
urine  containing  indican  has  been  standing  for  some  hours,  it  can 
generally  be  recognized  by  the  bluish  shimmer  of  the  residuum,  from 
the  drops  of  urine  from  the  upper  part  of  the  urine-glass  sprinkled 
and  spread  out  as  thin  as  possible,  and  sometimes,  also,  by  a  bluish 
film  upon  the  surface  of  the  urine.  Besides,  all  of  the  urine  is  some- 
times blackish-blue,  and  this  is  most  markedly  the  case  when  the 
urine  putrefies  (for  its  chemical  reaction,  see  below). 

Indican  urea  —  that  is  increase  of  the  indican — occurs  :  when 
there  is  accumulation  of  the  intestinal  contents,  especially  of  the  con- 
tents of  the  small  intestine,  hence  in  occlusion  of  the  intestine  from 
any  cause,  as  peritonitis  or  obstinate  obstipation;  likewise,  in  all 
forms  of  severe  cachexia,  as  well  as  in  Asiatic  cholera ;  lastly,  in 
individual  cases  in  health. 

Urobilin,  if  it  exist  in  considerable  quantity  in  the  urine,  colors  it 
a  decided  red  or  brownish-red.  The  foam  of  the  urine  sometimes 
looks  yellowish-red  or  yellowish-brown. 

While  there  is  only  a  small  quantity  of  it  in  health,  it  is  abundant 
in  febrile  diseases  and  where  there  is  at  any  time  resorption  of  large 
effusions  of  blood.  When  there  is  a  marked  separation  of  it  which 
continues  for  some  time,  a  brownish  discoloration  of  the  skin  is 
observed  in  the  so-called  urobilin-icterus,  though,  there  is  still  dispute 
as  to  its  nature. 

Proof  of  the  increase  of  indican  :  The  following  reaction  establishes 


410  SPECIAL  DIAGNOSIS. 

the  presence  of  indican  in  increased  amount,  because  it  does  not 
operate  in  the  presence  of  the  small  quantity  found  in  normal  urine. 
We  mix  equal  parts  of  urine  and  fuming  nitro-muriatic  acid  in  a 
reagent  glass ;  into  this  we  drop  two  to  three,  or  at  most  four,  drops 
of  a  concentrated  solution  of  chlorinated  potash  ;  immediately,  or  after 
a  few  seconds,  there  is  formed  just  beneath  the  surface  a  blue-black 
cloud — indigo-blue.  By  stirring  the  solution  of  potash  in  the  urine  we 
obtain,  according  to  the  quantity  of  indigo  formed,  a  more  or  less 
dark  coloration  of  the  whole  fluid.  If,  then,  we  add  a  few  drops  of 
chloroform  and  agitate  (not  shake)  the  reagent-glass  several  times,  we 
have  the  blue  color  at  the  bottom  from  the  settling  of  the  chloroform 
(it  becomes  green  if  too  much  of  the  solution  of  chlorinated  potash 
has  been  added,  from  the  further  oxidation  of  the  indigo-blue). 

Proof  of  urobilin.  1.  Spectroscopic  :  Absorption  bands  in  green- 
blue,  between  Frauenhofer's  lines  b  and  F  (sometimes  it  is  necessary 
to  dilute  the  urine  with  water,  in  order  to  be  able  to  make  the  exami- 
nation). 2.  Chemically  :  We  add  ammonia  to  the  reddish  urine  in 
the  reagent-glass.  If  there  is  much  urobilin  there,  it  gradually 
becomes  a  clear  green  ;  it  is  then  filtered ;  and,  sometimes,  upon  the 
addition  of  a  few  drops  of  a  watery  solution  of  chloride  of  zinc,  there 
appears  the  rose-red-greenish  fluorescence  that  is  peculiar  to  urobilin. 

2.  Discoloration  of  the  urine  from  the  presence  of  the  coloring- 
matter  of  the  blood,  and  of  the  bile.  That  of  the  blood  colors  the  urine 
variously  according  to  the  amount  that  is  mixed  with  the  urine,  also 
whether  it  is  fresh  or  has  been  changed,  and  according  to  the  original 
<;olor  (concentration)  of  the  urine  :  flesh-red  or  blood-red  with  green- 
ish shimmer  with  the  light  passing  through  it,  corresponding  to  the 
•dichrotic  behavior  of  the  blood  ;  or  an  untransparent  brown,  even 
Mackish.  Frequently  the  bloody  color  is  easily  recognized ;  but, 
generally,  the  reaction-test  for  blood  coloring-matter  is  necessary  (see 
Coloring  Matter  of  the  Blood). 

Colorinsj-matter  of  blood  occurs  in  the  urine  :  1.  In  hsematuria,  and 
this  in  the  sediment.  It  is  circumstantially  described  in  the  section 
on  Admixture  of  Blood  with  the  Urine.  2.  In  hsemoglobinuria. 
In  this  condition  the  haemoglobin  is  found  entirely  dissolved  or  in 
granular  lumps,  but  no  red  blood-corpuscles,  or  very  few,  are  found 
in  the  urine.  This  results  from  heemoglobingemia  (see  p.  271),  and 
this  condition  may  arise  from  very  different  causes :  from  poisons 
(chlorate  of  potash,  mineral  acids,  arsenical  solutions,  pyrogallic  acid, 


EXAMINATIOX  OF  THE  JRINARY  APPARATUS.  411 

Tiaplithol,  poison  of  the  edible  musliroom,  helvella  esculenta ;  after 
transfusion  of  animal  blood,  as  of  lamb's  blood) ;  in  infectious  diseases 
(as  scarlet  fever,  abdominal  typhus,  malaria,  syphilis) ;  after  extensive 
burns ;  lastly,  Ave  have  to  mention  a  form  of  hsemoglobinuria  which 
occurs  as  an  independent  disease — paroxysmal  lisemoglobinuria. 

Coloring  matter  of  the  bile  exists  in  the  urine  in  icterus  (icteric 
urine).  Such  urine  is  most  frequently  a  beer-brown,  sometimes  brown- 
green,  or  even  black.  If  the  urine  of  icterus,  as  is  very  seldom  the 
case,  is  very  thin,  then  it  may  have  a  golden-reddish  tone.  The 
foam  that  forms  when  it  is  shaken  is  then  highly  characteristic :  from 
clear  to  dark  yellow,  green-yellow,  even  brownish.  (Regarding  the 
chemical  tests  for  bile  coloring-matter,  and  more  particularly  regard- 
ing its  presence  and  that  of  the  bile  acids  in  the  urine,  see  section  on 
Coloring  Matter  of  the  Bile.) 

3.  Staining  of  the  urine  from  medicines.  It  is  very  important  to 
recognize  these  changes  in  color,  so  that  one  may  be  on  the  guard 
against  deception  by  confounding  them  with  the  coloring  matter  of 
the  bile  and  the  blood. 

The  chrysophanic  acid  contained  in  rhubarb  and  senna  passes  off 
hy  the  urine.  It  colors  the  urine  slightly,  making  it  at  most  a  little 
brownish,  if  it  is  normally  acid ;  but  if  it  is  alkaline,  or  is  made  so, 
then  it  becomes  a  purplish-red. 

After  taking  logwood,  alkaline  urine  also  becomes  reddish  or  violet. 

Santonin  colors  the  urine  yellow  or  greenish-yellow,  with  a  yellow 
foam  ;  upon  the  addition  of  an  alkali  the  color  changes  to  red.  Picric 
acid  makes  the  urine  yellow,  but  there  is  no  change  in  color  after 
changing  the  reaction. 

Carbolic  acid,  naphthalin,  creasote,  and  other  preparations  of  tar, 
as  well  as  the  infusion  of  the  leaves  of  uvse  ursi  (arbutin)  produce  a 
greenish  or  greenish-black  color  of  urine. 

Brownish  or  blackish  discoloration  of  the  urine  after  standing  for 
some  time  in  the  air  is  observed  in  patients  with  melanotic  tumors, 
because  the  pigment  which  forms  the  coloring  matter  of  the  blood  in 
those  tumors  passes  off  by  the  urine.  A  similar  behavior  of  the  urine 
is  found  in  the  presence  of  an  abnormal  amount  of  pyrocatechin,  an 
extremely  rare  occurrence. 

Transparency  of  the  urine.  A  loss  of  transparency  by  turbidness 
may  take  place  even  in  normal  urine  when  it  has  been  allowed  to  stand 
(see  above).     Urine  that  is  turbid  when  passed  is  always  pathological. 


412  SPECIAL    DIAGNOSIS. 

This  is  the  case,  first  of  all,  in  nephritis,  in  consequence  of  the  pres- 
ence of  organized  constituents  ;  in  all  diseases  of  the  urinary  passages, 
for  the  same  reason  (here  particularly  on  account  of  mucus) ;  but 
especially  in  severe  cystitis,  because  the  urine  in  this  condition  is 
alkaline  when  it  is  passed  (alkaline  fermentation  in  the  bladder),  and 
hence,  besides  the  organic  constituents,  contains  a  deposit  of  phos- 
phates. Admixture  of  blood  and  pus  always  makes  the  urine  turbid 
to  some  extent.  The  most  striking,  and,  at  the  same  time,  the  rarest 
kind  of  turbidness  is  that  caused  by  fat  in  the  urine,  chyluria.  Here 
the  urine  is  milky,  as  if  mixed  with  pus  (galacturia)  from  the  emulsi- 
fied fat;  or  it  contains  large  drops  of  fat  or  fat-bubbles  swimming 
upon  its  surface  (lipuria).  By  shaking  the  urine  up  with  ether  it 
becomes  clear.  But  when  it  is  allowed  to  stand,  part  of  the  fat  settles 
as  a  sediment,  and  part  forms  a  cream-like  layer  on  top.  (See  further 
regarding  Chyluria.) 

Tlie  Specific  Q-ravity  of  the  Urine  in  Disease. 

The  specific  gravity  of  the  urine  may  vary  from  a  little  over 
1000  to  over  lOGO  (in  diabetes  mellitus).  Apart  from  certain 
special  admixtures  (we  mean  particularly  sugar,  which  increases  the 
specific  gravity  without  changing  its  color,  and  the  special  pig- 
mentary admixtures,  which,  on  the  other  hand,  darken  the  color 
without  essentially  adding  to  the  specific  gravity),  almost  always  in 
disease,  as  in  health,  a  scanty,  dark  urine  has  a  high  specific  gravity ; 
an  abundant,  clear  urine,  a  low  specific  gravity.  According  to  Hsesef 
and  Neubauer,  from  the  specific  gravity  we  can  obtain  an  approxima- 
tion to  the  amount  of  solid  constituents  of  the  urine  by  multiplying 
the  last  two  figures  of  the  specific  gravity  by  2.33.  This  product 
represents  the  quantity  of  solid  constituents  in  1000  grammes  of  the 
urine.  If  we  have  1200  grammes  of  urine  with  a  specific  gravity  of 
1021,  then  1000  grammes  of  this  contains  21  X  2  33  =  48.93  grammes 
of  solids,  and  the  whole  amount  =  58.7  grammes.  But  not  much 
has  been  said  regarding  the  change  of  material  upon  which  it  chiefly 
depends,  because  the  different  solid  constituents  of  the  urine  have 
very  different  specific  gravity,  particularly  urea,  which,  as  compared 
with  chloride  of  sodium  is  as  2  to  3.  Hence,  we  can  never  draw  defi- 
nite conclusions  from  the  specific  gravity  alone,  and  even  where  we 
can  exactly  determine  the  solids,  as  by  examining  the  various  material 


EXAMINATION  OF  THE  URINARY  APPARATUS.  413 

changes,  the  quantitative  determination  of  the  urea  or  of  the  nitrogen 
is  indispensably  necessary. 

The  chief  value  in  the  determination  of  the  specific  gravity  with 
reference  to  diagnosis  consists  in  the  following : 

1.  High  specific  gravity  with  clear  and  abundant  urine  points  to 
diabetes  mellitus.  We  may  even  say  that  a  specific  gravity  of  1040 
and  over,  the  urine  being  clear,  can  only  be  caused  by  sugar,  and 
hence  is  pathognomonic  of  diabetes. 

2.  Repeated  or  continued  examination  of  the  urine  in  general 
engorgement  is  of  value,  because  this,  as  well  as  the  quantity  of  the 
urine,  measures  the  labor  of  the  heart. 

It  is  not  unimportant  to  know  further  : 

3.  A  low  specific  gravity,  when  there  is  a  small  amount  of  urine 
which  is  often  high  colored,  occurs  in  nephritis  from  diminished  excre- 
tion of  urea,  also  in  severe  diarrhoea  and  vomiting. 

Reaction  of  Urine  in  Disease. 

For  the  reasons  previously  given  (under  Reaction  of  the  Normal 
Urine),  the  reaction  of  the  urine  is  reliable  only  a  short  time  after  it 
has  been  passed. 

Neutral  or  alkaline  reaction  of  the  urine  is  met  with  in  sickness : 

1.  Under  the  same  conditions  that  make  it  neutral  or  alkaline  in 
health. 

2.  When  there  is  resorption  of  transudates  and  exudation  in  the 
cavities  of  the  body,  also  from  large  eS"usions  of  blood,  especially  in 
the  pleura  and  peritoneum. 

3.  With  dilatation  of  the  stomach,  and  particularly  if  the  contents 
of  the  stomach  must  frequently  be  brought  up,  either  by  vomiting  or 
artificially.  The  reason  given  is  that  the  blood  and  the  organism 
lose  their  acidity  because  free  HCl  is  not  again  resorbed  (?)  (See 
above,  under  Reaction  of  the  Normal  Urine.) 

4.  Considerable  admixture  of  blood  or  pus.  In  the  cases  of  alka- 
line urine  previously  mentioned  the  urine  is  clear,  or  is  turbid  from 
the  deposit  of  phosphate ;  it  contains  no  bacteria,  or  only  a  few. 

5.  With  alkaline  fermentation  of  the  urine  in  the  bladder.  This 
accompanies  severe  forms  of  cystitis.  Here  the  urine  is  turbid, 
because  of  the  presence  of  pus-corpuscles,  abundant  bacteria,  deposit  of 
triple-phosphates,  urate  of  ammonia,  carbonate  and  phosphate  of  lime 
and  magnesia.     Sometimes  it  has  a  peculiar,  urinous  smell,  and  is 


414  SPECIAL  DIAGNOSIS 

pungent  from  the  free  ammonia.  By  this  latter  a  strip  of  red  litmus- 
paper,  just  held  free  over  the  fluid,  is  colored  blue. 

Further  regarding  the  formed  constituents  of  simple  alkaline  urine, 
and  that  which  has  been  the  subject  of  alkaline  fermentation,  see 
under  Sediment. 

The  acidity  of  the  urine  may  be  determined  by  a  simple,  but 
really  not  very  accurate,  method :  Prepare  a  10-per-cent.  solution  of 
caustic  soda  (1  of  soda  to  9  of  distilled  water),  and  pour  this  from  a 
burette  into  the  urine  until  a  piece  of  very  sensitive  litmus  becomes 
blue.     1  c.cm.  of  the  soda  solution  corresponds  to  0.0068  of  oxalic  acid. 

Works  upon  analysis  of  the  urine  teach  the  more  exact  methods. 

Pathological  Odor  of  the  Urine. 

Here  we  must  mention  as  worthy  of  recognition  the  pathological 
departures  from  the  odor  of  normal  urine.  A  urinous,  more  or  less 
pungent,  ammoniacal  odor,  in  cases  of  severe  cystitis,  shows  ammo- 
niacal  fermentation  in  the  urine  that  is  passed.  Then  there  is  the 
feculent  odor  Avhen  the  urine  is  mixed  with  feces,  whether  the  admix- 
ture takes  place  after  the  urine  is  passed  (see  Contamination,  p.  399), 
or  whether  it  has  taken  place  from  communication  between  the  bladder 
and  the  intestine,  with  discharge  into  the  bladder. 

The  most  notable,  and  at  the  same  time  diagnostically  important, 
odor  of  the  urine  is  the  fruity  (apple-odor),  or  like  chloroform.  The 
substance  which  has  this  peculiar  odor  seems  to  be  acetone  (Fetters) 
[compare  what  is  said  later  regarding  Acetone].  The  urine  Avhich 
has  this  odor,  upon  the  addition  of  chloride  of  iron,  sometimes  gives  a 
burgundy-red  reaction  ("  chloride-of-iron  reaction,"  Gerhardt),  which 
shows  the  presence  of  acetoacetic  acid  (see  further  below).  Usually 
the  odor  of  apples  is  more  noticeable  in  the  breath  of  the  patient 
even  than  in  the  urine,  and  it  may  be  noticed  in  the  breath  alone. 

The  apple-odor  is  observed  in  individual  cases  of  diabetes  mellitus. 
It  especially  occurs  in  diabetic  coma  or  as  the  precursor  of  this  con- 
dition, but  it  also  exists,  and,  indeed,  often  for  a  long  time,  without 
the  occurrence  of  coma. 

Unusual  odors  may  be  imparted  to  the  urine  by  medicines  :  after 
taking  turpentine,  violet  odor;  after  cubebs  and  copaiva,  the  aromatic 
odor  of  these  drugs. 

Foul,  albuminous  urine,  but  especially  urine  that  contains  pus. 
develops,  as  the  result  of  certain  organisms,  sulphuretted  hydrogen  : 


EXAMINATION  OF  THE  URINARY  APPARATUS.  415 

hydrothionic  urine.  Sometimes  this  fermentation,  with  the  develop- 
ment of  sulphuretted  hydrogen,  seems  to  take  place  in  the  bladder 
(cystitis).  On  the  other  hand,  if  the  urine,  when  first  passed,  is 
clear,  and  upon  being  promptly  examined  is  found  to  contain  sul- 
phuretted hydrogen,  it  is  probable  that  there  has  been  resorption  of 
SH2  into  the  blood  or  into  the  bladder  from  the  intestine,  or  from  a 
depot  of  pus  in  the  neighborhood  of  the  bladder  ;  under  which  circum- 
stances the  general  symptoms  of  poisoning  have  recently  been  observed. 

Urinary  Sediments. 

We  are  to  call  to  mind  the  sediments,  previously  mentioned,  which 
may  occur  in  normal  urine.  On  the  other  hand,  these  same  sedi- 
ments may  sometimes  be  observed  as  pathological  signs,  as  is  shown 
in  Avhat  follows  : 

All  formed  constituents  which  separate  when  the  urine  is  allowed 
to  stand  are  reckoned  as  "sediments,"  whether  they  can  be  recog- 
ni-zed  with  the,  naked  eye  or  only  under  the  microscope,  or  whether 
they  are  organized  or  are  really  "deposits."  As  previously  men- 
tioned, in  order  to  examine  the  sediment  it  is  desirable  carefully  to 
pour  off  from  the  vessel  containing  the  urine  the  upper  part ;  the 
lower  turbid  or  already  settled  portion  is  to  be  put  into  a  glass  with  a 
pointed  bottom,  and  again  allowed  to  settle.  Then  follows  the 
examination  with  the  naked  eye  and  with  the  microscope.  For  the 
latter,  we  take  up  some  of  the  sediment  with  a  pipette  by  introducing 
it  closed  by  one  finger  upon  the  upper  end  to  the  bottom  of  the 
pointed  glass,  when  it  is  to  be  opened  again  for  a  moment,  then  it  is 
withdrawn  and  carefully  wiped  off,  and  a  drop  of  its  contents  allowed 
to  flow  upon  an  object-glass.  [A  slide  with  a  depression  in  the 
centre  making  a  shallow  cell  is  very  convenient,  since  a  larger  drop  can 
be  examined  at  each  time.]  Upon  this  we  place  a  glass  cover,  and 
examine  it  with  a  magnifying  power  of  about  400  diameters.  If  the 
sediment  is  very  scanty,  we  are  to  focus  the  microscope  so  as  first  to 
examine  the  edge  of  the  covering-glass.  It  may  happen  that  the 
sediment  is  so  scanty  that  we  cannot  see  anything  at  the  bottom  of 
the  glass  with  the  naked  eye,  but  by  carefully  removing  a  drop  from 
the  bottom  of  the  glass  and  placing  it  under  the  microscope  we  may 
possibly  make  out  formed  constituents,  as  a  few  casts  (contracted 
kidney). 

It  is  necessary  to  color  the  urinary  preparations  only  when 
examining  for  certain  microorganisms  (see  below). 


416  SPECIAL  DIAGNOSIS. 

1.   Sediments  of  Organic  Bodies  or  their  Direct  Products. 

Mucus.  Physiologically  this  exists  only  in  small  quantities.  It 
is  increased  in  all  diseases  of  the  urinary  passages,  but  especially 
in  cystitis,  and  also  in  fever. 

Some  mucous  forms  are  characteristic  :  In  the  form  of  minute 
roundish  floccules,  the  size  of  a  millet-seed  or  the  head  of  a  pin,  they 
are  tolerably  characteristic  of  mild  cystitis.  Under  the  microscope 
they  show  white  blood-corpuscles  lying  closely  to  one  another,  and 
they  are  apparently  conglomerations  of  white  corpuscles. 

In  the  form  of  threads,  one  to  two  centimetres  long — gonorrhoeal 
threads — sometimes  more  purely  mucous  in  character,  and,  again, 
containing  abundant  pus-corpuscles:  they  occur  in  chronic  gonorrhoea 
or  as  the  residuum  of  a  past  attack. 

Finally,  we  find  microscopical  mucous  threads,  cylindroids  (see 
Fig.  123,  p.  417),  which  may  be  confounded  by  the  inexperienced 
with  tube-casts.  The  origin  and  diagnostic  significance  of  these 
is  not  clear.  They  are  found  in  nephritis  by  the  side  of  the  casts, 
in  cystitis,  but  also  in  health.  They  are  distinguished  from  the 
urinary  casts  by  their  usually  being  of  considerable  length,  their 
mucus-thread  texture,  their  very  varying  thickness  (as  fine  as  threads, 
especially  at  the  end),  and  their  tape-like  appearance. 

Chemical  proof  of  mucus  in  solution  :  The  addition  of  acetic  acid 
makes  a  flocculent  precipitate,  which  is  not  again  dissolved  by  an 
excess  of  acid,  nor  is  it  again  dissolved  by  heat,  as  is  the  case  with  a 
precipitate  of  urates  produced  by  acetic  acid. 

In  Avomen  mistakes  may  arise  from  the  admixture  of  vaginal  mucus 
with  the  urine. 

Blood,  or  red  blood-corpuscles.  The  appearance  of  the  urine  varies 
very  remarkably  in  hsematuria.  Sometimes  there  is  a  considerable 
bloody  sediment,  not  infrequently  partly  coagulated ;  again,  only  a 
fine  deposit  of  red  blood-corpuscles  spread  out  evenly :  and  lastly, 
sometimes,  a  more  brown-red,  clear,  or  dark -brownish  sediment.  The 
red  blood-corpuscles  may  be  so  scanty  as  to  escape  detection  with 
the  naked  eye.  This  distinction  pertains  to  the  amount  of  the  blood 
and  its  having  been  for  a  longer  or  shorter  time  in  the  urine — that 
is,  with  reference  to  the  location  of  the  hemorrhage.  (Regarding  the 
color  of  the  urine,  see  p.  401.) 


EXAMINATION  OF  THE  URINARY  APPARATUS. 


417 


Fig.  123. 


Hcematuria  occurs  : 

(a)  In  diseases  of  the  kidneys — that  is  to  say,  in  acute  and  chronic 
hemorrhagic  nephritis,  in  embolic  hemorrhagic  infarction  of  the  kidney 
(valvular  disease  of  the  heart),  in  septic 
hemorrhage  of  the  kidneys  (acute  en- 
docarditis), in  marked  engorgement  of 
the  kidney,  with  new  formations,  and, 
lastly,  in  injuries  to  the  kidney. 

{h)  In  certain  diseases  of  the  urinary 
passages,  and  also  of  the  pelvis  of  the 
kidney  (nephrolithiasis,  tumors),  of  the 
hladiler  (severe  cystitis,  tumors,  stone), 
of  the  urethra  (gonorrhcea  with  parasites 
of  the  urinary  canal ;  see  below). 

Moreover,  hgematuria  has  symptoma- 
tic significance  for  recognizing  diseases 
of  other  kinds.  Thus  it  occurs  in  scor- 
butus, morbus  Werlhofii,  haemophilia, 
and,  lastly,  in  the  rare  hemorrhages  of 
the  kidney  or  urinary  tract  that  are  due 
to  leukaemia. 

From  the  appearance  of  the  sediment 
and  the  way  it  is  passed,  a  conclusion 
with  i-eference  to  the  location  of  the 
hemorrhage  and  the  kind  of  disease  Avill 
be  made  from  the  following  points  of 
view : 

A  small  amount  of  blood,  or,  at  least 
a  not  too  abundant  quantity  of  blood, 
uniformly  mixed  with  the  urine,  the  color 
of  the  blood  being  retained,  or,  more 
frequently,  changed  into  a  brownish 
color,  points  to  a  hemorrhage  of  the  kid- 
ney. That  this  is  its  source  can  be  more  certainly  proved  by  the 
microscope  showing  blood-casts  (see  below).  Where  there  is  renal 
hemorrhage,  the  blood-corpuscles  are  always  more  or  less  discolored, 
as  rings  or  shadows.  Cells  and  casts,  if  present,  are  stained  brown 
by  the  coloring-matter  of  the  blood.     A  brown  color  of  the  sediment 

27 


CyIindroids{seep.  416).   (Jaksch.) 


418  SPECIAL  DIAGNOSIS. 

and  of  tlie  urine  indicates  acute  hemorrhagic  nephritis.  The  sudden 
occurrence  of  bloody  urine,  with  valvular  disease  of  the  heart,  points 
to  renal  infarction.  Individual  red  blood-corpuscles  occur  in  very 
concentrated  urine  in  renal  engorgement. 

In  hemorrhage  of  the  pelvis  of  the  kidney,  especially  that  caused 
by  stope,  the  urine  usually  alternates  between  being  bloody  and  free 
from  blood,  and  this,  either  because  there  are  temporary  hemorrhages 
or  because  the  ureter  of  the  diseased  side  is  for  the  time  being  stopped, 
and  then  the  urine  that  is  passed  only  comes  from  the  sound  side. 
The  blood  may  for  a  time  escape  very  freely;  in  rare  cases  it  may  be 
passed  in  the  form  of  vermiform  coagula  (casts  of  the  ureter),  which 
give  great  pain  as  they  are  passed. 

Cystic  hemorrhages,  especially  in  villous  tumors,  may  be  so  free  as 
to  be  fatal.  The  urine  is  not  intimately  mixed  with  blood,  especially 
if  the  patient  lies  quietly  in  bed ;  at  first  there  is  little  or  no  blood  at 
each  urination ;  but  then,  again,  pure  blood  is  sometimes  passed.  On 
the  other  hand,  in  hemorrhage  from  the  urethra,  blood  comes  only  at 
the  beginning  of  the  urination.  Here,  sometimes,  there  is  an  escape 
of  blood  between  the  urinations.  Works  upon  surgery  treat  more  at 
length  of  hemorrhages  of  the  bladder  and  urethra. 

Microscopical  examiyiation.  In  every  respect  this  is  the  most 
valuable  method  for  recognizing  hsematuria,  especially  from  the 
following  points  of  view:  1.  Because  the  separate  red  blood-corpuscles 
can  be  discovered  where  neither  the  fluid  portion  of  the  urine  nor  the 
sediment  shows  the  color  of  blood,  and  where,  also,  the  fluid  portion 
does  not  show  the  reaction  of  the  blood-pigment  (see  below).  2. 
Because  it  alone  establishes  the  differential  diagnosis  between  hsema- 
turia and  hsemoglobinuria.  3.  Because,  from  the  condition  of  the 
red  bloo^-corpuscles,  from  the  presence  of  possible  blood-casts  (see 
Casts),  we  can  sometimes  determine  that  there  is  renal  hemorrhage. 

In  haematuria  we  find  more  or  less  abundance  of  red  corpuscles. 
In  decided  hemorrhage,  especially  from  the  lower  portion  of  the 
urinary  tract,  these  are  only  slightly  changed.  If  retained  for  some 
time  in  the  urine,  and  particularly  if  they  are  scanty,  us  in  renal 
hemorrhage,  they  are  smaller,  have  granular  contents,  or  are  more  or 
less  markedly  discolored.  If  they  are  very  pale,  then  we  have  the 
so-called  rings.  If  there  are  no  red  blood-corpuscles  in  a  urine  that 
is  bloody  and  certainly  contains  haemoglobin  (see  Examination  of  the 


EXAMINATION  OF  THE  URINARY  APPARATUS.  419 

dissolved  portion),  or  if  they  are  very  scanty  in  a  urine  that  contains 
a  good  deal  of  haemoglobin,  then  we  have  htemoglobinuria  (which 
see). 

Besides  red  blood-corpuscles,  we  frequently  find  in  the  sediment, 
according  to  the  disease  present,  still  other  formed  constituents :  in 
cystitis,  first  of  all,  white  blood-corpuscles,  phosphate  crystals ;  in 
nephritis,  casts  and  white  blood-corpuscles.  A  considerable  amount 
of  blood  in  the  urine  makesit  somewhat  albuminous. 

With  women,  we  must  remember  the  possibility  of  beino-  deceived 
by  the  menstrual  blood. 

Hcemoglohin.  In  hsemoglobinuria  there  is  usually  a  brown  or 
brown-black  sediment,  which  consists  of  brown  flakes  and  fine  granular 
detritus.  A  few  red  blood-corpuscles  are  likewise  found.  If  casts 
and  epithelium  are  present,  they  are  often  colored  brown. 

Pus,  or  white  blood- corpuscles.  It  is  rare  that  a  considerable 
amount  of  pus  is  passed  by  the  urethra.  It  happens  if  a  neighboring 
depot  of  pus  breaks  into  the  urinary  canal :  in  perinephritic  abscess 
with  discharge  into  the  pelvis  of  the  kidney,  but  particularly  in  ab- 
scesses of  all  kinds  in  the  neighborhood  of  the  bladder.  Here  the 
discharge  of  pus  takes  place  suddenly,  and  after  a  short  time  the 
urine  becomes  normal  again.  But  the  discharge  of  pus  into  the 
urinary  passage  may  continue  for  some  time,  or  it  may  indicate 
cystitis. 

Sediments  of  pus  or  white  blood-corpuscles  are  more  frequent, 
being  caused  by  inflammation  of  the  mucous  membrane  of  the  urinary 
tract,  or  by  nephritis.  In  the  latter  case  they  are  less  abundant  than 
in  the  former.  The  sediment  is  yellow  to  white,  in  nephritis;  in 
catarrhal  cystitis  it  is  sometimes  very  like  phosphatic  sediment  (which 
see).  In  inflammation  of  the  urinary  tract,  generally  the  sediment 
becomes  a  peculiar  compact  jelly,  from  mucus;  in  alkaline  urine,  it  is 
due  to  the  mucous  swelling  of  the  white  blood-corpuscles  (see  above); 
in  nephritis,  it  is  quite  spongy. 

The  microscopical  examination  shows  the  white  blood-corpuscles 
more  or  less  changed  according  to  their' amount,  the  length  of  time 
they  have  been  in  the  urine,  and  the  reaction  of  the  latter.  In  alka- 
line urine  they  are  very  clear  and  much  swollen.  Of  the  diseases  of 
the  kidneys,  acute  hemorrhagic   nephritis,  and  sometimes  the  sub- 


420  SPECIAL  DIAGNOSIS. 

chronic  (chronic  parenchymatous)  nephritis,  show  a  relatively  abundant 
amount  of  pus-corpuscles. 

To  a  slight  degree,  pus  makes  the  urine  albuminous  ;  a  considerable 
amount  of  albumin  in  the  urine  is  always  due  to  renal  albuminuria. 
When  the  quantity  of  albumin  in  the  urine  is  slight,  the  question 
may  arise  whether  we  have  nephritis,  either  as  a  separate  disease  or 
as  a  complication  of  cystitis  or  pyelitis.  This  can  only  be  answered 
by  the  infallible  sign  of  nephritis — that  is,  easts  in  the  urine. 

Fat-drops.  The  fat  accompanying  chyluria  may,  as  was  previously 
mentioned,  exist  in  the  urine  as  a  sediment,  but  also  as  a  cream-like 
or  swimming  layer,  or  in  the  form  of  large  drops.  We  must  remember 
that  it  may  be  due  to  impurities,  as  the  use  of  an  oiled  catheter.  The 
microscope  shows  minute  particles  of  fat  or  large  drops,  which 
markedly  refract  the  light.  In  the  first  case  the  fatty  character  of 
the  sediment  may  be  most  quickly  recognized  by  the  grease-spot 
formed  upon  paper  by  the  sediment.  We  may  also  shake  it  up  with 
ether,  and  then  allow  the  ether  to  escape  by  evaporation. 

The  occurrence  of  fat-drops  free  and  attached  to  casts,  adipose 
Avhite  blood-corpuscles,  is  very  important  in  diagnosing  large  white 
kidney. 

EpitheUum.  We  find  in  the  urine  the  epithelium  of  the  urinary 
passages  and  the  epithelium  of  the  renal  urinary  channels  [urinary 
tubules].  In  addition,  in  women  we  have  very  frequently,  but  espe- 
cially when  there  is  leucorrhoea,  flat  epithelium  from  the  vulva.  The 
epithelial  cells  in  transition  are  everywhere  very  similar.  But  renal 
epithelium  is  usually  easily  recognized  as  such. 

While  in  normal  urine  only  individual  flat  epithelial,  and  some- 
times, caudate  cells  occur,  we  meet  a  large  quantity  of  the  three 
species  of  cells  named  in  inflammation  of  the  urinary  passages. 
Usually,  they  are  well  preserved.  It  is  misleading  to  form  a  conclu- 
sion from  the  kind  of  cells  as  to  the  location  of  the  inflammation 
(especially  Avhether  of  the  pelvis  of  the  kidney  or  of  the  bladder). 
The  vulva  being  excluded,  a  large  quantity  of  flat  epithelium  points 
to  the  bladder.  Abundant  caudate,  but  especially  overlapping,  "  tile- 
like," roundish  cells  with  large  nuclei,  were  formerly  often  regarded 
as  characteristic  of  inflammation  of  the  pelvis  of  the  kidney ;  but 
more  recently  this  view  has  come  into  discredit. 


EXAMINATION  OF  THE  URINARV  APPARATUS. 


421 


Renal  epithelia  occur  in  considerable  numbers  only  in  affections  of 
the  kidney,  and  especially  in  nephritis.  If  their  form  is  well  pre- 
served, they  are  recognized  without  difficulty  as  polygonal  or  round- 
cornered  cells  of  peculiarly  sharp  contour,  with  large  oval  nuclei  and 
a  decidedly  granular,  often  yellowish-looking,  protoplasm.  They  are 
small — not  larger  than  white  blood-corpuscles,  sometimes  smaller.  In 
acute  hemorrhagic  nephritis  they  are  often  coarsely  granular,  brownish 
in  color;  in  the  large  white  (butter)  kidney,  but  sometimes  also  in  the 
first  disease,  we  not  infrequently  see  them  in  all  stages  of  fatty 
degeneration. 

Fig.  124. 


Epithelium  from  the  urine,  a,  h,  epithelium  from  the  bladder,  from  the  pelvis  of 
the  kidney;  c,  caudate  epithelium  (pelvis  of  the  kidney?);  d,  renal  epithelium, 
partly  changed  into  fat. 

Regarding  cylindrical  epithelium,  see  under  Casts. 

Shreds  of  tissue.  Shreds  of  connective-tissue  ^nd  "  caseous 
crumbs  "  are  found  in  tuberculosis  of  the  urinary  apparatus. 

Particles  of  carcinomatous  tissue  are  separated  in  carcinoma,  but 
are  more  frequently  found  in  carcinoma  villosum  of  the  bladder. 
Only  particles  which  distinctly  show  the  structure  of  carcinomatous 
tissue  are  of  importance  here.  Single,  or,  also,  several  pretended 
"  cancer-cells  "  lying  close  to  one  another  have  no  diagnostic  value. 

Si^ermatozoa.  After  every  discharge  of  semen  these  aro  seen  in 
the  urine.  Hence,  they  arc  not  unimportant  for  detecting  masturba- 
tion. They  also  occur  in  spermatorrhoea.  Lastly,  sometimes  they 
are  found  after  epileptic  attacks ;  also,  now  and  then  with  severe 
diseases  of  all  kinds,  as  in  typhoid  fever  patients. 

Casts.  The  so-called  urinary  casts  (Henle,  1842)  are  incontestably 
the  most  important  form-elements  in  pathological  urine.     They  are 


422  SPECIAL  DIAGNOSIS. 

found  with  renal  albuminuria.  Aside  from  quite  individual  excep- 
tional cases,  they  occur  without  simultaneous  albuminuria  only  in  one 
condition :  hepatogenous  icterus.  Here  they  have  no  diagnostic 
interest  further  than  that,  from  their  occurrence,  we  may  suspect  the 
presence  of  bile-acids  in  the  urine.  They  are  intensely  stained  with 
the  bile-pigment. 

We  concern  ourselves  only  with  the  occurrence  of  casts  with  albu- 
minuria. By  their  presence  these  not  only  permit  a  conclusion  that 
there  is  a  disease  of  the  kidneys  which  causes  albuminuria,  but,  by 
their  quantity  and  character,  also  enable  us  to  diagnose  the  exact 
nature  of  the  disease.  Regarding  their  numbers  the  casts  are  scanty, 
and  then  usually  hyaline  (see  below),  in  engorgement  of  the  kidneys, 
in  fever,  in  physiological  albuminuria ;  and,  lastly,  they  are  tem- 
porarily present  in  contracted  and  amyloid  kidney.  There  is  often 
here  a  sediment  which  is  scarcely,  or  not  at  all,  visible.  In  making 
a  preparation  we  must,  with  the  greatest  care,  take  a  few  drops  from 
the  bottom  of  the  urine-glass  and  examine  the  preparation  with  great 
thoroughness.  It  is  advantageous,  but  not  indispensable,  to  stain  any 
casts  that  may  be  present  by  the  addition  of  a  little  gentian- violet 
solution  placed  upon  the  edge  of  the  covering-glass.  The  casts  are 
very  abundant  in  acute,  and  frequently  also  in  chronic,  nephritis. 
In  these  diseases  they  may  form  the  principal  portion  of  a  tolerably 
abundant  sediment. 

Variation  in  the  quantity  of  the  casts  is  to  be  observed  in  all  the 
diseases  named.  Sometimes  it  seems  as  if,  after  a  period  of  stagna- 
tion, the  casts  are  passed  in  greater  abundance.  This  is  not  very 
rare  in  amyloid  nephritis,  also  in  acute  attacks  of  nephritis. 

In  size  and  form  the  casts  vary  greatly.  We  will  speak  further 
regarding  this. 

As  to  their  nature,  we  distinguish  the  following  kinds  of  casts  : 

Hyaline  casts.  These  are  of  great  variety  as  to  length  and 
breadth  ;  sometimes  not  so  broad  as  a  white  blood-corpuscle  (thin 
hyaline  casts),  and,  again,  five  or  six  times  as  broad  (thick  or  medium 
casts).  In  length  they  may  be  as  much  as  one  millimetre.  They 
are  homogeneous  and  clear  as  water,  with  a  very  fine  outline,  hence 
often  very  difficult  to  see ;  the  ends  look  as  if  broken  off",  rounded,  or 
even  clubbed  (for  aggregation  of  substances  within  them,  see  below). 
They  occur  in  company  with  other  forms  in  all  diseases  of  the  kidney. 


EXAMiyATIOy  OF  THE  URINARY  APPARATUS. 


423 


Exclusively  hyaline  casts  occur  most  frequently  in   contracted  and 
amyloid  kidney,  also  in  fever  and  with  [renal]  engorgement. 

A  special  kind  of  hyaline  casts  are  the  waxy,  so  named  from  their 
dull  lustre  and  usually  yellowish  color.  Sometimes  they  show  the 
amyloid  reaction  with  iodine  and  iodide  of  potassium — brown,  then 
violet  with  sulphuric  acid.  We  cannot  form  a  conclusion  from  them 
as  to  the  nature  of  the  disease 

of  the  kidney  ;    certainly  they  Fif._  126. 

are  not  pathognomonic  of  amy- 
loid kidney. 

Additions  to  the  hyaline,  and 
also  to  the  waxy,  casts  fre- 
quently occur  in  the  form  of  liili 
red  and  white  blood-corpuscles, 
renal  epithelium,  crystals,  gran- 
ular masses,  which,  in  turn, 
may  show    urates,   phosphates, 

Fifi.  125. 


Hyaline  easts  (narrow  and  tolerably 
broad  ones). 


Waxy  casts.    (Jaksch.)     5,  a  cast  containing 
crystals  of  oxalate  of  litne. 


albuminous  or  fat  granules,  and,  lastly,  bacteria.  Among  these 
additions  those  of  special  significance  are  red  blood-corpuscles,  as  in 
hemorrhagic  nephritis,  possibly  adipose  renal  epithelia,  white  blood- 
corpuscles  (granular  spheres),  and  free  fat-granules.  These  adipose 
elements,  if  abundant,  are  important  for  the  diagnosis  of  large  white 
or  fatty  kidney. 

In  some  cases  of  pyelonephritis  we  have  seen  hyaline  casts  which 


424 


S  FECI  A  L  D I  A  GNOSIS. 


were  split  like  a  pair  of  trousers.  These  might  possibly  have  their 
origin  in  collective  tubes  (?). 

Casts  that  are  coarse  or  finely  granular  are  generally  hyaline,  with 
additions  to  their  contents,  as  above.  But,  especially  in  acute 
nephritis,  conglomerate  casts  of  albumin  in  lumps  and  granules  also 
occur ;  sometimes  stained  or  mixed  with  hsematoidin. 

Blood  easts  are  conglomerations  of  red  blood-corpuscles  held 
together  by  coagulation.  They  are  important  as  indisputable  signs  of 
renal  hsematuria. 

Epithelial  casts  are  either  hyaline  casts  with  the  addition  of  renal 
epithelium  (recognized  by  their  sharp  outline  and  distinct  large 
nuclei),  or  they  are  true  epithelial  tubes.  In  both  cases  they  have 
the  same  significance — the  free  desquamation  of  renal  epithelium, 
especially  as  it  occurs  with  acute  hemorrhagic  nephritis. 


Fig.  127. 


Fig.  128. 


Fig.  129. 


Fig.  127.— Granular  casts.     (Jaksch.) 

Fig.  128. — Red  blood-corpuscles,  partly  as  "  rings''  and  cast   of  red  blood-corpuscles. 

(ElCHHORST.) 

Fig.  129. — Epithelial  cast.     (Jaksch.) 

Casts  of  lumps  of  haemoglobin  in  hsemoglobinuria,  urate-casts  in  the 
newly  born  (uric  acid  infarction  in  connection  with  ammonium  urate), 
and  casts  of  bacteria  in  pysemia  (?)  are  very  rare  occurrences. 

We  may  confound  casts  with  cylindroids  (see  p.  416),  also  with 
threads  of  linen  or  other  adventitious  materials  in  the  urine.  Practice 
in  examining  and  cleanliness  guard  one  from  mistake 

Animal  Parasites. 

Uehinococcus.  Shreds  from  echinococcus  bladders,  scolices,  are 
met  with  in  the  urine  if  an  echinococcus  of  the  kidney  oi  from  the 


^EXAMINATION  OF  THE  URINARY  APPARATUS.  425 

neighborhood  of  the  urinary  apparatus  breaks  into  the  urinary  passage. 
The  passing  of  urine  is  often  attended  with  severe  pain,  especially  by 
attacks  of  colic  during  its  transit  through  the  ureters.  They  may  be 
preceded  by  anuria  from  obstruction  of  the  urethra,  obstruction  of 
one  ureter,  and  "reflex"  suppression  of  secretion  upon  the  sound 
side  (or  reflex  spasm  of  the  sphincter  vesicae). 

Distoma  hcematobium,  an  exotic  from  Egypt,  located  in  the  roots  of 
the  portal  vein,  also  particularly  in  the  plexus  vesicalis,  causes  h^ema- 
turia.      The  eggs  of  the  parasite  make  their  appearance  in  the  urine. 

Strongylus  gigas  located  in  the  pelvis  of  the  kidney  causes  pyuria 
and  hsematuria. 

Filaria  sanguinis,  an  exotic  from  East  India,  Japan,  China,  and 
Australia,  located  in  the  large  lymph-vessels,  among  other  things 
causes  engorgement  of  the  lymph-vessels  of  the  bladder :  chyluria  (and 
likewise  galacturia,  see)  and  hsematuria  (peach-red  urine).  Besides, 
the  urine  contains  embryo  filaria,  round  worms  of  delicate  structure, 
lying  in  a  fine  sheath,  with  lively  motion.  Its  width  is  about  that  of 
a  red  blood-corpuscle  ;  its  length,  two  to  three  millimetres. 

Oxyuris  vermicidaris,  trichomonas  vaginalis  (an  infusorium),  and, 
in  one  case  under  my  observation,  the  larva  of  a  fly,  musca  vom- 
itoria  (!),  may  become  mixed  with  the  urine  from  the  vagina. 

Vegetable  Parasites  and  Fungi. 

Normal  fresh  urine,  free  from  impurities,  is  not  entirely  free  from 
fungi  (see  p.  399).  A  number  of  bacilli  and  cocci  colonize  in  urine 
that  has  been  standing  for  some  time,  of  which  those  of  special  interest 
are  the  ones  which  cause  alkaline  fermentation,  changing  the  urea 
into  carbonate  of  ammonia  (see  p.  402). 

The  micrococci  and  bacilli  of  alkaline  fermentation,  and,  with  them, 
the  signs  of  this  fermentation — alkaline  urine,  crystals  of  triple- 
phosphate  and  carbonate  of  ammonia  (see  below) — however,  occur  in 
fresh  urine  in  severe  cystitis,  particularly  as  the  result  of  the  use  of  a 
catheter  that  is  unclean,  in  cases  of  weak  or  paralyzed  bladder;  but 
this  is  no  doubt  also  caused  by  paralysis  of  the  bladder  alone,  and  the 
spontaneous  entrance  of  fungus  germs  through  the  urethra.  The 
fungi  produce  cystitis  by  the  fermentation  they  set  up,  and  this,  in 
turn,  favors  the  development  of  the  fungi.  If  these  schizomycetes 
are  very  numerous  they  may  form  the  greater  part  of  the  abundant 


426  SPECIAL  DIAGNOSIS. 

sediment.  Under  the  microscope  we  see  ciiiefly  the  chain-coccus 
(micrococcus  urese,  micrococcus  urese  liquifaciens)  and  bacilli  (chiefly 
bacillus  urese,  Leube),  not  so  long,  but  thicker  than  the  bacillus 
tuberculosis;  all  these  forms  of  fungi  being  in  the  most  lively  motion. 
It  is  the  presence  of  these  fungi  that  distinguishes  simple  alkaline 
urine  (see  p.  413)  from  urine  that  is  alkaline  from  fermentation. 

Tubercle  bacilli  in  the  urine  are  an  absolutely  sure  sign  of  ulcer- 
ating urogenital  tuberculosis.  But  in  this  disease,  especially  when 
there  is  tuberculosis  of  the  pelvis  of  the  kidney  or  of  the  kidney  of 
only  one  side,  the  ureter  of  that  side  is  temporarily  or  permanently 
stopped.  In  regard  to  the  occurrence  of  single  bacilli  having  the 
form  and  the  color-reaction  of  tubercle  bacilli,  compare  what  has  been 
said  regarding  smegma  bacilli,  p.  400.  If  tubercle  bacilli  appear  at 
all  in  the  urine,  they  are  generally  abundant,  not  infrequently  even 

Fig.  130. 


Pure  culture  of  tubercle  bacilli  in  the  urine  in  tuberculosis  of  the  genito-urinary 
apparatus.  Zeiss's  homogeneous  immersion  one-twelfth  eye-piece  No.  4.  Drawn  with 
a  camera  lucida.     Magnified  about  1100.     Author's  observation. 

in  masses  and  with  an  arrangement  which  reminds  one  of  a  pure 
culture.  Fig.  130  exhibits  an  excessive  dev^elopment  of  this  kind 
(personal  observation).  In  purulent  urinary  sediment  they  can  be 
demonstrated  just  as  distinctly  as  in  the  sputum.  If  there  is  decided 
anaemia,  wasting,  and  continued  fever,  as  well  as  in  cases  of  long- 
continued  gleet,  every  purulent  urinary  sediment  should  be  examined 
for  tubercle  bacillus. 


EXAMINATION  OF  THE  URINARV  APPARATUS.  427 

Gonococci(Neisser) occur  in  the  pus  of  recent  gonorrhoea  in  clusters, 
in  epithelial  cells,  and  in  pus-cells.  The  latter  circumstance  is  char- 
acteristic of  gonococci,  and  distinguishes  them  from  other  bacteria 
which  resemble  them.  Gonococci  are  chiefly  met  with  as  diplococci, 
and  since  the  individual  coccus  seems  to  be  divided  into  two  by  a 
bright  transverse  band,  it  often  makes  the  so-called  roll-form.  In 
gleet  and  in  pervsons  who  have  formerly  had  gleet,  but  have  for  years 

Fig.  131. 


Gonococci  iu  the  pus  from  the  urethra.     Zeiss's  homogeneous  immersion  one-twelfth, 
eye-piece  'No.  2     Drawn  with  a  camera  lucida.     Magnified  about  650. 


been  free  from  any  symptoms,  we  find  a  diplococcus  which  resembles 
the  gonococcus.  But  by  recent  investigations  it  has  been  discovered 
that  even  in  the  urethral  secretion  of  persons  in  health,  who  have 
never  had  gonorrhoea,  there  occurs  a  diplococcus,  free  as  well  as 
enclosed  in  epithelia  (although,  of  course,  not  in  pus-corpuscles). 
This  diplococcus  hns  a  form  very  much  like  the  gonococcus  (Lust- 
garten  and  Mannaberg).  The  gonococcus  is  to  be  stained  with 
gentian-violet  or  methylene-blue,  or  fuchsin,  and  then  rinsed  in  water. 

Pathogenic  fungi  which  circulate  in  the  blood  are,  in  individual 
cases,  found  in  the  urine :  thus,  tubercle  bacilli  in  acute  miliary 
tuberculosis,  equinia,  erysipelas  cocci  in  erysipelatous  nephritis 
(Fehleisen),  spirillum  recurrens  in  complicating  hemorrhage  of  the 
kidney  (Kanncnberg),  pus-micrococci  in  pysemia  and  endocarditis 
(Weichselbaum).  Also,  casts  of  micrococci  are  described  in  septic 
processes  (Litten  and  others). 

Lastly,  in  cases  of  acute  nephritis,  bacteria  have  recently  been  found 
in  the  urine  and  in  the  kidney,  which  have  been  regarded  by  different 
authors  as  the  specific  excitants  of  the  nephritis.  These  cases  are  too 
much  isolated  to  permit  us  to  form  a  definite  conclusion  as  yet. 


428  SPECIAL  DIAGNOSIS. 

A  small  form  of  sarcina  is  found  rarelj  in  alkaline  fermentation  in 
the  urine.  It,  as  well  as  the  other  fungi  named,  is  regarded  as  the 
cause  of  the  transformation  of  the  urea.  Leptothrix  buccalis  occurs 
as  a  foreign  substance,  as  from  the  preputial  sac  (Huber). 

The  occurrence  of  the  yeast  fungus,  saccharorayces,  in  urine  con- 
taining sugar  is  not  unimportant.  Here  it  causes  acid  fermentation. 
In  urine  that  does  not  contain  sugar,  some  yeast-cells  are  found  occa- 
sionally, but  they  do  not  increase. 

2  Inorganic  Sediments. 

These  consist  of  materials  which  are  ordinarily  found  in  the  urine 
in  a  state  of  solution,  but  which,  for  various  reasons,  are  absent, 
chiefly  because  the  urine  is  very  much  concentrated,  or  because  its 
reaction  has  changed.  These  bodies  show  the  forms  of  more  or  less 
pure  crystals ;  they  may  be  crystalline,  or  amorphous,  but  neverthe- 
less often  have  a  peculiar  symmetrical  form.  Here  we  really  consider 
the  finer  urinary  sediments  ;  urinary  calculi,  which  belong  to  surgery, 
will  be  mentioned  at  the  end  and  only  very  briefly. 

(a)  The  more  frequent  inorganic  sediments.  From  acid  urine 
there  are  deposited: 

Uric  acid,  uric  acid  salts  (sodium,  lime),  oxalate  of  lime. 

From  the  faintly  acid,  neutral  (amphoteric),  alkaline  urine  there 
are  deposited: 

Ammonio-magnesian  phosphates,  phosphate  of  lime,  carbonate  of 
lime,  urate  of  ammonia,  and  sometimes  uric  acid. 

All  these  substances  may  occasionally  be  deposited  from  healthy 
urine  (see  p.  402) 

Uric  acid.  As  is  stated  above,  we  find  this  as  a  deposit  not  only 
in  acid,  but  sometimes  in  neutral  and  alkaline,  urine.  It  can  often 
be  recognized  with  the  naked  eye  in  the  form  of  yellowish-red, 
glittering  granules,  which  are  located  upon  the  side  of  the  urine-glass, 
or  in  the  form  of  a  yellowish-red  powder  at  the  bottom  of  the  glass. 
Uric  acid  deposited  from  the  urine  always  has  this  yellowish-red 
color,  while  the  chemically  pure  uric  acid  is  colorless.  Under  the 
microscope  it  shows  the  greatest  variety  of  crystal  forms  and  crys- 
talline figures  (see  Fig.  132).  The  basis  form  is  the  rhomboidal 
plate.     But  this  is  rare.      More  frequently  we  have  derivatives  of 


EXAMINATION  OF  THE   URINARY  APPARATUS. 


429 


this,  the  so-called  ''whetstone  "  (with  a  cross  or  in  druses),  ''barrel- 
shaped,''  also  peculiar  bundles  of  prisms,  lastly,  amorphous  lumps  and 
clubs  with  separate,  shining,  smooth  surfiices — all  easily  recognized 
by  their  distinct  color.  AVe  may  artificially  produce  a  separation  of 
uric  acid  deposit  by  adding  to  the  urine  some  concentrated  solution 
of  salt  and  allowing  it  to  stand  for  twenty-four  hours.  Ordinarily, 
chemical  reaction  is  not  necessary. 


Fig.  132. 


Fig.  133. 


Urie  acid  iind  urates.     (Funke.) 


Oxalate  of  lime.     (Laachk. 


The  occurrence  of  uric-acid  crystals  in  the  urine  only  shows  that 
uric  acid  is  not  exactly  Avanting  in  the  urine,  and  nothing  more.  It 
is  said  that  the  frequent  separation  of  amorphous  forms  indicates 
urinary  calculi  (Ultzmann). 

Urate  of  soda  and  lime.  When  concentrated  urine  cools  there  is 
often  a  very  abundant  sediment,  colored  a  flesh-red  by  the  urinary 
pigment,  "brick-dust  sediment,"  or  sedimeiifiim  lateritium.  When 
cooled  to  zero,  C,  we  can  obtain  it  from  any  urine.  It  will  be  most 
easily  recognized  by  the  fact  that  it  immediately  completely  dissolves 
when  the  urine  is  warmed  (not  boiled,  because  then  there  is  a  phos- 
phatic  cloudiness,  and  also  coagulation  of  albumin,  if  present).  Under 
the  microscope  the  urates  of  soda  and  of  lime  are  seen  as  very  fine 
grains.  .  They  incline  to  settle  upon  the  casts,  and  especially  upon 
mucus  threads.  Uric-acid  crystals  form  about  half  an  hour  after  the 
addition  of  some  muriatic  acid. 

From  concentrated  urine  the  lateritious  sediment  is  deposited  at 


430 


SPECIAL  DIAGNOSIS. 


the  ordinary  temperature  of  the  room,  especiallj  in  engorgement  of 
the  kidneys,  in  attacks  of  diarrhoea,  in  fever,  and  also  in  health  (see 
p.  402).  We  should  never  conclude  from  its  presence  that  there  is 
increased  separation  of  uric  acid.  AVe  can  only  determine  this  by 
ascertaining  the  amount  of  uric  acid  and  urate  separated  in  twenty- 
four  hours. 

Oxalate  of  Iwie.  Single  crystals  of  this  may  appear  in  any  urine 
that  has  been  standing  for  some  time.  The  crystals  are  almost  always 
tolerably  small,  sometimes  minute  regular  octahedra,  which  are  con- 
spicuous by  their  perfect  form  and  strong  refraction  of  light  (envelope- 
form).  They  are  rarely  hour-glass-  and  dum.b-bell-shaped.  The 
crystals  are  insoluble  in  Avater,  and  are  thus  distinguished  from 
chloride  of  sodium. 


Fig.  134. 


Fig.   135. 


Triple-phosphates  ;   urate  of 
ammonia.     (Laache.) 


Phosphate  of  lime.     (Laache.) 


These  crystals  occur  in  the  urine  in  great  abundance  after  eating 
certain  fruits  and  vegetables,  as  apples,  pears,  cauliflower,  and  the 
different  kinds  of  sorrel;  and  also  in  diabetes  mellitus,  catarrhal 
icterus,  hypochondria.  Moreover,  we  cannot  conclude,  without 
further  evidence  than  the  mere  occurrence  of  a  somewhat  large  amount 
of  these  crystals,  that  there  is  increased  separation  of  oxalic  acid 
(oxaluria).  The  disease  described  by  English  physicians  (and  Can- 
tani)  as  oxaluria  does  not  seem  to  be  a  unity.  This  oxaluria  occurs 
in  cachexia  (tuberculosis,  cancer). 


EXAMIXATION  OF  THE  URINARV  APPARATUS. 


431 


Amiiioiuarn-iiiagnesian  jjliospliate  (triple-phosphate)  is  found  in 
urine  that  is  simply  alkaline  and  that  is  undergoing  alkaline  fermenta- 
tion. Sometimes  it  forms  the  principal  portion  of  the  Avhitish  sedi- 
ment. The  basis  form  is  the  rhombic  prism ;  it  is  well  formed  in  the 
"coffin-lid  crystals,"  often  also  of  various  other  forms,  and  is  then 
more  difficult  to  recognize.  The  triple-phosphates  are  all  perfectly 
colorless, 'and  soluble  in  acetic  acid,  thus  contrasting  with  oxalate  of 
lime. 

Phosphoric  acid  as  a  basic  salt  occurs  in  amorphous  grains  in 
alkaline  fermentation  of  the  urine.  It  is  soluble  in  acetic  acid,  but 
not  by  heat.  As  a  neutral  salt  it  occurs  in  simple  alkaline  urine  in 
the  form  of  long  Avedgos  or  knife-blades.  These  disappear  in  alkaline 
fermentation. 

Fig.  136.  Fig.  1.37.  ' 


Carbonate  of  lime.     (Laache.)  Leucin  and  tyrosin.     (Laache.) 

Carbonate  of  lime,  in  the  form  of  spherules  or  crossed  drum-sticks, 
seldom  occurs  in  alkaline  urine.  ["  In  highly  alkaline  urine,  in 
which  the  alkalescence  is  caused  by  carbonate  of  ammonia  set  free  by 
decomposition  of  urea,  carbonate  of  lime  occurs  in  small  quantity,  but 
in  an  amorphous  form.  This  is  the  only  form  in  which  I  have  yet 
seen  carbonate  of  lime  in  human  urine." — Beale.]  It  is  dissolved 
by  the  addition  of  muriatic  acid,  with  eifervescence. 

The  so-called  phosphaturia  is  a  condition  in  which  phosphates  and 
carbonates  ai-e  precipitated  before  or  immediately  after  the  urine  is 
passed.       But   there  is   no  increase  in  the  phosphoric    acid.       The 


432  SPECIAL  DIAGNOSIS 

precipitation  is  probably  produced  by  the  alkalinity  of  the  urine. 
Phosphaturia  occurs  in  neurasthenia,  hypochondria,  chronic  articular 
rheumatism. 

Urate  of  ammonia  accompanies  triple-phosphate  in  alkaline  fer- 
mentation. The  characteristic  form  is  that  of  the  thorn-apple 
(grayish-yellow  or  brownish  opaque  balls,  from  which  fine  needles 
project).  When  muriatic  acid  is  added,  there  develop  under  the 
covering-glass  uric-acid  crystals. 

(5)  3Iore  rare  inorganic  sediments.  Hsematoidin  is  exceptionally 
found  in  the  forms  of  needles  and  plates  mentioned  before  (p.  180). 
Sometimes  we  see  white  blood-corpuscles  which  contain  hsematoidin 
needles,  which  project  through  the  cell-membrane. 

Leucin  and  tyrosin  (see  Fig.  137).  The  characteristic  forms  of 
these  substances,  which  almost  always  appear  together,  are  sometimes 
found  in  the  sediment,  more  often  only  when  we  have  evaporated  the 
urine  in  a  water-bath  to  the  consistence  of  syrup,  or  until  we  slowly 
boil  down  a  drop  of  urine  upon  an  object-glass  until  it  is  almost  dry. 
Leucin  appears  in  the  form  of  faintly  shining  spheres,  which  some- 
times, if  they  are  large,  show  radiating  lines  and  concentric  rings. 
Tyrosin  crystallizes  in  very  fine  needles,  which  commonly  form 
druses  and  bundles. 

Leucin  and  tyrosin  are  products  of  the  decomposition  of  albumin. 
They  do  not  occur  in  normal  urine.  Diseases  in  which  they  are 
found  and  for  which  they  may  have  diagnostic  value,  are  acute  yellow 
atrophy  of  the  liver  and  acute  poisoning  by  phosphorus.  They  are 
also  seen  in  variola  and  typhus  abdominalis  [typhoid  fever],  as  well 
as  in  pernicious  anaemia  (Laache). 

Cystin  sometimes  occurs  in  the  urine  in  health.  Large  quantities 
of  cystin  in  the  urine  may  cause  the  formation  of  cystin-calculi  and 
excite  cystitis,  and  are  thus  a  pathological  condition  in  themselves. 
According  to  recent  investigations  (Baumann,  Brieger)  there  seems  to 
be  a  connection  between  the  occurrence  of  ptomaines  and  cystin  in 
the  urine.  Brieger  assumes  that  by  the  presence  of  certain  ptomaines 
in  the  intestinal  canal  (hence,  in  mycotic  enteritis)  the  cystin  forms  a 
combination  with  the  ptomaines  in  the  intestine,  which  overflows  into 
the  urine.  There  the  compound  decomposes,  and  cystin  is  again  set 
free.  Sometimes  this  does  not  take  place,  and  so  calculi  are  formed. 
The  ptomaines,  in  turn,  may  cause  inflammation,  especially  cystitis. 


EXAMINATION  OF  THE  URINARY  APPARATUS.  433 

Cystin,  besides  occurring  in  the  urine  in  the  form  of  calculi,  is  seen 
in  the  form  of  extremely  thin,  six-sided,  and  very  perfectly  formed 
colorless  plates. 

(c)  Concretions  in  tlie  urine.  We  are  interested  only  in  the  con- 
cretions that  arise  in  the  pelvis  of  the  kidney,  as  in  nephrolithiasis, 
pyelitis  calculosa.  Those  that  form  in  the  bladder  belong  to  surgery. 
The  former  are  named,  according  to  their  size,  renal  sand,  renal 
gravel,  renal  calculi.  If  they  attain  a  certain  size,  they  cause  severe 
attacks  of  pain  in  their  transit  through  the  urethra  (renal  calculi 
colic).  Most  frequently  the  concretions  consist  chiefly  of  uric  acid 
and  urates.  They  are  then  brown  or  brown-black,  and  tolerably 
smooth  on  the  surface.  Stones  of  oxalate  of  lime  are  densely  hard 
and  have  a  rough  surface  (mulberry  calculi) ;  they  are  dark  brown. 
A  combination  of  layers  of  uric  acid  and  oxalate  of  lime  is  likewise 
met  -with.  Phosphatic  calculi  are  tolerably  soft,  but  not  iiifrequently 
they  contain  a  kernel  of  the  first-named  substances  (phosphate  de- 
posited upon  the  stone  from  the  alkaline  urine  of  cystitis  [excited  by 
the  original  stone].  Finally,  we  must  mention  stones  of  cystin  and 
(extremely  rare)  xanthin.  All  these  stones,  with  the  exception  of  the 
phosphatic  calculi,  are  formed  in  acid  urine. 

For  the  exact  chemical  examination  of  the  concretions  we  refer  to 
the  text-books  upon  Urinary  Analysis. 

Examination  of  the  Urinary  Constituents  in  Solution. 

1.  Anomalies  in  the  Quantity  of  tlte  Normal  Constituents. 

In  disease  the  normal  constituents  of  the  urine  are  variously  increased 
or  diminished.  These  quantitative  variations,  however,  can  only  excep- 
tionally be  made  use  of  for  the  diagnosis  of  disease.  But  they  are 
important  for  determining  the  change  of  material  and  the  removal  of 
material  that  can  be  carried  oil  by  the  urine  in  various  diseases.  This 
requires  throughout  an  exact  quantitative  analysis,  for  the  different 
"  approximative  methods  "  have  no  value  at  all.  We  cannot  here  go 
into  an  explanation  of  the  exact  methods,  but  must  refer  to  the  hand- 
books upon  urinary  analysis.  However,  w^e  mention  briefly  the  most 
important  anomalies  which  belong  here.  Wo  have  already  mentioned 
the  quantities  of  the  normal  constituents  of  the  urine,  p.  404. 

Urea.     This  is  increased  in  fever,  either  absolutely,  as  in  pneu- 

28 


434  SPECIAL  DIAGNOSIS. 

monia,  or  relatively — that  is,  in  relation  to  diminution  in  the  amount 
of  food  taken.  It  is  also  increased  in  diabetes.  We  find  it  diminished 
in  all  forms  of  nephritis,  but  especially  in  uraemia ;  in  cachexia  of  all 
kinds,  especially  if  there  is  dropsy ;  and,  lastly,  sometimes  in  acute 
yellow  atrophy  of  the  liver.  The  very  decided  increase  in  the  amount 
of  excretion  of  urea  which  takes  place  immediately  after  the  crisis  in 
pneumonia  is  designated  as  post  epicritical.  It  is  probably  con- 
nected with  the  increase  in  the  amount  of  water  secreted  by  the 
kidney. 

Sehrwald  has  recently  {Milnchen  med.  Wochenschrift,  1888,  No. 
46)  devised  a  simplification  of  Knop-Hiifner's  method  of  determining 
the  amount  of  urea,  which  seems  to  us  to  be  very  practical  and  rela- 
tively exact.  We  have  not  yet  had  an  opportunity  to  test  thoroughly 
the  method.     At  least,  we  recommend  that  it  be  tried. 

Uric  acid  is  usually  increased  in  fever  parallel  with  the  urea. 
Besides,  it  is  increased  in  leukaemia  and  pernicious  anaemia  (with  the 
first,  often  very  markedly),  also  in  all  diseases  which  afiect  the  inter- 
change of  gases  in  the  lungs  ;  and,  lastly,  with  the  uric-acid  or  gouty 
diathesis,  apart  from  attacks  of  gout,  during  which  it  is  often  dimin- 
ished. 

The  total  amount  of  nitrogenous  material  in  the  urine,  the  most 
important  for  determining  the  metamorphosis  of  tissues,  approximately 
afrrees  with  the  amount  estimated  from  the  urea,  because  the  uric 
acid,  kreatinin,  and  xanthin  bodies  are  insignificant  in  amount  com- 
pared with  the  urea.  Besides,  the  most  practicable  method  for  the 
quantitative  determination  of  the  urea  (Liebig's)  is  really  a  determina- 
tion of  the  total  amount  of  nitrogen,  expressed  as  urea  (C.  Voit, 
Salkowski,  and  Leube).  When  determining  both  nitrogen  and  urea, 
of  course,  it  must  be  done  apart  from  any  possible  albumin — that  is 
to  say,  the  latter  must  first  be  removed. 

Chloride  of  sodium  is  pathologically  increased  during  the  resorp- 
tion of  transudations  and  exudations,  and  also  in  intermittent  fever, 
from  the  destruction  of  red  blood-corpuscles  (Kast).  It  is  diminished 
in  fever,  nephritis,  and  in  many  cachectic  conditions.  [In  pneumo- 
nia, during  the  stage  of  exudation  and  until  resolution  begins,  the 
chlorides  are  diminished  or  disappear  from  the  urine.  While  the  dis- 
appearance of  the  chlorides  from  the  urine  is  not  characteristic  of 


EXAMINATION  OF  THE  URINARY  APPARATUS.  435 

this  disease  alone,  it  shows  that  exudation  is  still  going  on,  or  that 
resolution  has  not  yet  commenced.] 

Sulphuric  acid  interests  us  chiefly  with  reference  to  the  associated 
ethylsulphuric  acid  (phenol-,  indoxyl-sulphuric  acids).  It  is  found 
with  increased  separation  of  indican  and  carbolic  acid.  Reo-ardino- 
the  former,  see  p.  409.  The  latter  occurs  with  the  internal  and 
external  use  of  carbolic  acid. 

It  has  been  found  that  the  phosphates  are  diminished  in  rhachitis, 
also  in  acute  yellow  atrophy  of  the  liver.  In  nephritis  they  are  not 
infrequently  diminished. 

2.  Abnormal  Constituents. 

Albuynin.  Except  in  the  rare  cases  of  physiological  albuminuria 
already  mentioned,  any  separation  of  albumin  in  the  urine  is  patho- 
logical. This  is  always  so  if  it  continues.  The  albuminous  substances, 
which  in  the  conditions  reckoned  as  albuminuria  in  the  narrow  sense 
can  be  separated,  are  serum-albumin  and  serum-globulin.  Their 
amount  varies  from  a  trace  to  one-half  per  cent. — very  exceptionally 
more.  Generally,  it  remains  below  one-half  per  cent.  The  secretion 
of  hemialbuminose  is  very  rare,  and  thus  far  has  not  been  found  to 
have  special  diagnostic  significance.  Of  late,  we  are  not  accustomed 
to  regard  peptonuria  as  albuminuria.  It  will  be  considered  at  the 
close  of  this  chapter. 

Albuminuria  occurs  : 

1.  As  true  renal  albuminuria,  in  all  forms  of  acute  and  chronic 
nephritis,  in  amyloid  kidney,  in  f  ngorgement  of  the  kidneys ;  in 
hydremic  conditions  of  the  blood,  as  anaemia,  ieuksemia ;  in  fever, 
and  in  acute  poisoning ;  in  these  two  cases,  especially  in  the  latter, 
there  occur,  besides  all  the  transitions  to  nephritis ;  lastly,  after  epi- 
leptic attacks,  apoplexy  (transitory  albuminuria). 

Besides,  there  has  recently  been  discovered  a  peculiar  form  of 
albuminuria  which  is  distinguished  from  other  forms  by  the  absence 
of  all  pathological  signs  in  the  urine,  especially  of  cylinders  :  cyclic 
albuminuria.     See,  regarding  this,  p.  437. 

2.  Further,  albumin  in  solution  in  the  urine  may  also  pass  over 
into  the  urinary  passages  when  blood  and  pus  are  mingled  with  the 
urine  in  the  bladder.  The  amount  of  albumin,  however,  is  always 
small. 

Qualitative  tests  for  albumin.  We  select  a  few  from  the  great 
number  of  tests  for  albumin,  which  have  the  tolerably  uniform  approval 


436  SPECIAL  DIAGNOSIS. 

of  authors  (see,  regarding  them,  Penzoldt's  Old  and  New  Urinary 
Tests),  and  which,  according  to  our  experience,  have  the  preference. 

The  preliminary  condition  is  that  the  urine  be  not  contaminated, 
as  by  menses  or  leucorrhoea,  and  that  it  be  clear.  The  latter  is  the 
more  necessary  in  proportion  as  the  amount  of  the  albumin  is  small. 
In  order  to  be  able  to  discover  it  when  only  a  very  little  is  present, 
it  is  necessary  to  filter  the  urine  until  it  is  perfectly  clear. 

(a)  Addition  of  acetic  acid  and  ferro-cyanide  of  potassium.  By  the 
acetic  acid  the  urine  is  rendered  distinctly  acid,  and  then  the  cold 
urine  is  mixed  Avith  a  few  drops  of  a  watery  solution  of  potas.  ferro- 
cyanide.  Even  with  a  very  small  amount  of  albumin,  very  fine 
floccules  are  formed,  often  almost  milky  cloudiness,  though  when  there 
is  only  a  very  small  quantity  of  albumin  it  is  somewhat  delayed. 
This  very  certain  and  distinct  test  is  strongly  recommended  for  use  at 
the  house  of  the  physician. 

(h)  Boiling  and  the  addition  of  nitric  acid.  If  the  urine  is  neutral 
or  alkaline,  acetic  acid  must  be  added  to  it  to  render  it  acid  before 
boiling.  If  there  is  cloudiness,  it  can  only  be  due  to  one  of  two 
causes :  albumin  or  phosphates.  To  determine  which  of  these  it  is, 
we  add  about  ten  drops  of  nitric  acid,  when  the  phosphatic  deposit  is 
immediately  dissolved ;  but  if  the  deposit  is  of  albumin,  it  is  made 
more  distinct,  When  the  albumin  is  somewhat  abundant,  the  deposit 
can  be  immediately  recognized  by  its  floccular  appearance.  The 
test  is  a  sharp  one,  showing  even  0.005  to  0.01  per  cent,  of  albumin, 
and,  being  tolerably  certain,  is  in  general  to  be  recommended. 

(c)  Picric-acid  test.  We  add  to  the  urine  a  few  drops  of  a  con- 
centrated watery  solution  of  picric  acid  :  if  it  immediately  becomes 
cloudy,  it  shows  albumin ;  but  cloudiness  appearing  later  shows 
nothing  (Johnson,  Penzoldt).  It  is  a  certain  and  sharp  test,  not  less 
to  be  recommended  than  the  others. 

As  portable  tests  for  albumin,  we  can  proportionally  recommend  the 
following  as  best : 

(d)  Geisler's  albumin  test-papers.^  These  consist  of  a  piece  of 
filter-paper  saturated  with  a  concentrated  solution  of  citric  acid,  and 
of  another  saturated  v/"ith  a  three-per-cent.  solution  of  iodide  of  potas- 
sium added  to  a  twelve  or  fifteen-per-cent.  solution  of  corrosive  subli- 

[1  They  may  be  obtained  of  Parke,  Davis  &  Co.,  and  other  manufacturing  chemists.] 


EXAMINATION  OF  THE  URINARY  APPARATUS.  437 

mate.  We  first  put  one  of  the  strips  of  the  first  into  the  urine — if 
very  alkaline,  more  than  one — then  one  of  the  second  papers,  and 
shake  it.  Cloudiness  due  to  albumin  appears  pretty  promptly.  Pep- 
tone is  also  precipitated,  which,  in  many  cases,  can  cause  deception 
(see  Peptonuria).  In  concentrated  urine,  urates  are  also  precipitated, 
but  these  can  afterward  be  dissolved  by  heat.  Deception  from  the 
.solution  of  particles  of  paper  making  a  cloudiness  is  not  possible,  if  it 
is  carefully  examined.  As  a  preliminary  test  at  the  sick-bed,  this 
method  is  to  be  recommended.  But  we  ought  not  to  be  satisfied  with 
its  result,  and  should  always  afterward  employ  one  of  the  tests  pre- 
viously mentioned. 

If  we  examine  the  urine  a  number  of  times  in  twenty-four  hours, 
and  find  that  there  is  a  periodic  presence  and  absence  of  albumin,  we 
designate  this  condition  as  cyclic  albuminuria.^  It  never  occurs  after 
rest  at  night ;  the  albumin  is  generally  separated  after  exertion.  In 
case  this  condition  is  suspected,  we  are  to  examine  the  urine  several 
times  during  the  day,  and  especially  toward  evening,  also  directly 
after  rising;  in  the  morning. 

Klemperer  has  made  a  very  clear  demonstration  of  the  course  of 
the  separation  of  the  albumin.  He  places  about  five  com.  of  the 
urine,  passed  at  different  times  during  the  day,  in  a  series  of  reagent- 
glasses,  and  then  boils  them  with  the  addition  of  nitric  acid.  The 
height  of  the  deposit  in  the  glasses,  as  they  are  arranged  in  a  row,  may 
be  regarded  as  a  direct  delineation  of  the  "albumin  curve." 

Quantitative  test  for  albumin.  Here,  as  in  all  quantitative  de- 
terminations, the  urine  of  exactly  twenty-four  hours  must  be  mixed, 
and  a  portion  from  this  mixture  examined.  The  urine  for  exactly 
twenty-four  hours  can  be  obtained  if  we  have  the  patient  urinate 
early,  say  shortly  before  seven  o'clock,  and  then  keep  all  the  urine 
that  is  passed  till  the  next  morning  at  exactly  the  same  hour,  passing 
his  urine  again  at  seven  o'clock. 

It  is  possible  to  make  an  exact  quantitative  determination  only  by 
completely  separating  the  albumin  from  a  measured  quantity  of  urine. 
Filter,  wash  the  residue  upon  the  filter-paper,  dry,  and  weigh  it.  (For 
particulars  regarding  these  processes,  see  text-books  upon  Urinary 

[1  In  the  British  Medical  Journal,  January  31,  1891,  p.  218,  Dr.  Herringham  gives  a 
valuable  and  careful  study  of  a  case  of  Cyclical  Albuminuria  which  was  under  his  care 
at  the  West  London  Hospital. — Translator.] 


438 


SPECIAL  DIAGNOSIS. 


Fig.  138. 


t^^ytM 


Analysis.)  This  examination  can  only  be  conducted  in  a  laboratory. 
There  is  no  mode  of  procedure  Avhich  is  more  simple,  nor  one  that  is 
so  nearly  exact  as  this.  The  polarizing  method  is  only  applicable 
when  there  is  a  considerable  amount  of  albumin. 

A  substitute  for  the  exact  quantitative  determination  is  quite  com- 
monly found  by  endeavoring  to  estimate  the  amount  of  deposit  which 
results  from  the  qualitative  determination,  especially  by  the  boiling 
nitric-acid  test :  we  wait  along  time — till  it.  settles  in  the  reagent- 
glass — and  then  we  speak  of  one-half,  one-quarter,  or  the 
whole  being  albumin,  by  comparing  the  volume  of  albu- 
min that  can  be  seen  with  the  whole  amount  of  urine  in 
the  reagent-glass.  It  may  be  assumed  that  one-half  the 
volume  of  albumin,  if  the  reagent-glass  has  stood  for  one 
hour,  corresponds  to  about  0.2  to  0.6.  This  estimate  is 
extremely  unreliable,  being  chiefly  dependent  upon  the 
size  and  thickness  of  the  flakes  of  ajlbumin.  But,  if  we 
always  employ  the  same  test  for  albumin,  it  is  certainly 
not  valueless  forjudging  of  the  variations  in  the  separa- 
tion of  albumin  in  the  course  of  disease. 

More  exact  is  the  method  with  Esbach's  albuminometer, 
although  it  acts  upon  the  same  principle,  and  so  is  only 
approximative.  What  exactness  it  has  depends  in  reality 
upon  the  employment  always  of  the  same  reagents,  mix- 
ing them  with  an  equal  amount  of  urine,  and  always 
allowing  the  same  time  for  the  deposit  of  the  precipitate. 
Tlie  albuminometer — a  graduated  thick  reagent-glass 
— is  filled  with  urine  to  the  mark  U,  from  there  to  R 
with  the  reagent.  This  reagent  consists  of  10  grammes 
of  picric  acid  and  20  grammes  of  citric  acid  to  1000  of 
distilled  water.^  The  glass  is  then  closed  with  a  rubber 
cork,  turned  upside  down  ten  times,  and  allowed  to  stand  undis- 
turbed for  twenty-four  hours,  best  in  a  special  stand.  After  this 
period  of  time  we  notice  at  Avhat  mark  of  the  scale  on  the  glass  the 
albuminous  deposit  stands.  The  marks  each  give  one-tenth  per  cent, 
of  albumin.     As  the  scale  only  goes  as  far  as  0.7  per  cent.,  urine  that 


Esbach's 

Albuminom 

eter. 


1  The  exact  amounts  of  both  acids  (chemically  pure  and  dry)  are  to  be  dissolved  in 
1000  grammes  of  water,  made  hot,  and,  after  cooling,  any  deficit  in  the  amount  of  fluid 
is  to  be  made  up  .by  the  addition  of  water  to  1000  grammes. 


EXAMINATION  OF  THE  URINARY  APPARATUS.  439 

is  strongly  albuminous  must  be  diluted  in  a  definite  way  before  the 
test.  We  must  avoid  producing  air-bubbles,  because  these  cause  the 
precipitate,  or  a  part  of  it,  to  swim,  and  for  this  reason  we  are  not  to 
shake  the  glass.  If  there  are  air-bubbles,  they  mast  be  removed  with 
a  pipette. 

In  most  cases  the  method  is  tolerably  exact  (an  error  of  one-tenth 
to  two-tenths  of  albumin),  but  in  individual  cases,  and  often  without 
any  recognizable  cause,  the  precipitate  does  not  sink  down  as  Avell  as 
it  usually  does.  Nevertheless,  it  is  to  be  recommended  as  an  improve- 
ment upon  the  simple,  rough  "  volumetric  "  estimate.  [The  apparatus 
is  not  at  all  expensive.  It  c:in  be  obtained  in  New  York  of  Eimer  & 
Amend.] 

Rare  Forms  of  Albumin. 

Peptone  (von  Jaksch,  Maixner,  and  others).  This  never  occurs  in 
healthy  urine.  Pathologically,  it  occurs  sometimes  in  ordinary  albu- 
minuria, and,  again,  independently — peptonuria.  It  occurs  in  a  great 
number  of  very  different  conditions  :  in  large  abscesses,  in  emphy- 
sema, sometimes  in  pneumonia;  likewise  in  acute  rheumatism,  scor- 
butus, phosphorus- poisoning;  also,  in  carcinoma  ventriculi,  in  puerperal 
fever,  in  typhus  abdominalis  [typhoid  fever],  etc.  Hence,  this  very 
remarkable  substance  has  no  value  for  diao;nosis.  Its  determination, 
even  qualitative  (biuret  reaction),  is,  for  various  reasons,  diflBcult. 

Hem^ialhumose  (hemialbuminose,  propeptone)  very  rarely  exists  in 
the  urine  (albumosuria).  There  must  arise  a  suspicion  of  these 
albuminous  bodies,  which,  according  to  the  latest  researches,  show  a 
mixture  of  four  albuminous  substances  (Kiihne,  K.,  and  Chittenden), 
if  there  is  a  precipitate  in  the  urine  after  it  has  been  subjected  to  the 
boiling  and  nitric-acid  test.  For  demonstrative  tests,  see  the  text- 
books upon  the  subject.  Hitherto  this  substance  has  had  no  diag- 
nostic significance. 

Kahler  has  recently  observed  hemialbumose  in  multiple  primary 
lymph o-sarcoma  of  the  spinal  cord. 

Fibrin  occurs  in  the  urine  in  hsematuria,  in  deep-seated  inflamma- 
tion of  the  urmary  passages,  in  tuberculosis,  in  poisoning  with  can- 
tharides,  and  in  chyluria.  It  is  recognized  by  the  fact  that  it 
coagulates  spontaneously  in  the  urine,  although  sometimes  only  after 
the  urine  has  stood  for  some  time.  The  coagula  are  then  to  be 
further  examined. 


440  SPECIAL  DIAGNOSIS. 

In  this  place  are  to  be  mentioned  two  phenomena  that  occur  in 
those  diseases  of  the  kidney  that  stand  in  close  relation  to  albumin- 
uria: dropsy  and  ursemia. 

The  dropsy  of  Iddacu  disease  manifests  itself,  very  frequently,  first 
in  the  skin  of  the  face,  especially  at  the  eyelids.  "With  contracted 
kidney  the  oedema  is  very  fugitive,  often  changing  its  place ;  in  a 
large  number  of  cases,  it  is  entirely  wanting  during  the  entire  course 
of  the  disease.  With  large  white  kidney  it  is  more  decided  and  stable ; 
there  is  often  a  very  soft,  doughy  oedema.  In  this  respect  acute 
nephritis  varies  very  much.  In  all  forms  of  Bright's  disease,  from 
its  association  with  heart- weakness,  a  new  factor  may  come  into  play 
for  the  development  or  increase  of  the  oedema  and  effusion  into  the 
cavities  of  the  body  (dropsy  of  engorgement). 

With  reference  to  the  cause  of  the  dropsy  in  kidney-disease,  no 
doubt  the  most  important  element  is  the  diminished  elimination  of 
water  by  the  kidneys.  This  retention  of  water  often,  especially  if 
excessive,  has  the  effect  that  even  a  slight,  perhaps  a  scarcely  notice- 
able, dropsy  of  the  skin  and  subcutaneous  tissue  considerably  disturbs 
the  excretion  of  water  by  perspiration.  At  any  rate,  it  is  certain  that 
the  dropsy  of  kidney-disease  is,  in  many  cases,  not  explained  by  the 
retention  cf  water  ;  but  neither  is  Cohnheim's  hypothesis,  that  the 
walls  of  the  vessels  are  abnormally  pervious,  at  all  generally  accepted. 
This  whole  matter  is  still  an  open  question. 

Uraemia  is  an  association  of  nervous  manifestations  which,  at  least 
in  the  majority  of  cases,  is  dependent  upon  the  retention  in  the  blood 
of  urinary  products  (especially  uric  acid).  In  individual  cases  of 
"  ursemic  "  manifestations,  however,  this  explanation  is  not  correct, 
and  the  nature  of  such  cases  is  not  yet  clear  (oedema  of  the  brain  (?), 
Traube;  sometimes  anatomical  changes  in  the  brain  (?),  Striimpell, 
etc.).  We  coincide  with  Striimpell's  view,  that  ui'semia  is  a  multi- 
farious condition — a  number  of  conditions,  which  by  their  presence 
and  their  phenomena  seem  to  belong  together,  are  in  reality  different. 
•  Slight  ursemic  symptoms  may  last,  with  slight  changes,  for  weeks, 
even  months,  as  somnolence,  restlessness,  headache,  malaise,  vomiting, 
dyspnoea  (ursemic  asthma),  indications  of  Cheyne-Stokes  respiration, 
slight  transitory  disturbances  of  vision.  The  more  severe  symptoms 
are :  decided  cloudiness  of  intelligence,  even  to  coma  or  delirium ; 
maniacal  conditions ;  convulsions,  from  single  convulsive  movements 


EXAMINATION  OF  THE  URINARY  APPARATUS.  i4l 

to  pronounced  epileptic  attacks ;  and  temporary  amaurosis.  There 
may  be  slowness  of  the  pulse,  with  acceleration  later,  and  fever.  In 
individual  cases  there  occur  evident  symptoms  of  cerebral  congestion; 
convulsions,  paraesthesia,  paralysis  of  an  arm  or  of  one  side  of  the 
body,  and  aphasic  manifestations. 

Mucin.  It  has  already  been  mentioned  when  this  appears  in  the 
urine.  When  the  mucin  is  dissolved,  its  presence  can  be  established 
by  the  addition  of  acetic  'acid :  it  forms  a  flocculent,  thready  pre- 
cipitate in  cold  urine,  which  is  not  again  dissolved  by  an  excess  of 
acetic  acid. 

Coloring-matter  of  the  blood.  The  occurrence  of  this  body  has 
also  been  previously  mentioned  (p.  410).  Here  we  have  to  refer  to 
testino;  for  hsemoo-lobin,  or  hsematin  in  solution. 

First,  it  must  bo  mentioned  that,  of  course,  the  urine  shows  the 
presence  of  albumin  in  both  hasmaturia  and  heemoglobinuria.  The 
amount  of  albumin  is  always  small,  provided  there  is  no  albuminuria 
besides. 

Blood-Figment  will  be  shown  to  be  present  by  the  following  pro- 
cedures : 

(a)  Heller  s  test.  A  portion  of  urine  is  made  decidedly  alkaline 
with  caustic  potash,  and  boiled  in  a  reagent-glass  :  the  phosphates 
are  precipitated  as  very  delicate  floccules,  which  look  like  mucus,  and 
slowly  sink  to  the  bottom.  They  accompany  the  blood-pigment,  and 
hence  look  brown  or  red-yellow.  When  the  urine  is  concentrated,  we 
dilute  it,  after  boiling,  by  filling  the  reagent-glass  with  water,  because 
the  color  of  the  floccules  is  easily  concealed.  Urine  that  is  poor  in 
phosphates,  as  in  nephritis,  gives  no  phosphatic  deposit.  Such  urine 
must  be  mixed  with  some  that  has  the  normal  amount  of  phosphates, 
before  making  the  test.  The  color  described  as  belonging  to  the 
phosphatic  deposit  occurs  nowhere  else,  except  with  urine  containing 
chrysophanic  acid,  but  this  latter  is  recognized  by  its  changfe  in  color 
after  the  reaction.  This  test  is  very  simple,  certain,  and,  with  clear 
urine,  is  tolerably  distinct. 

(b)  Test  with  tincture  of  guaiac.  The  reagent  consists  of  tinct. 
guaiac,  ol.  terebinth,  ozonisat.,  aa  10  parts.  A  small  portion  of  this, 
placed  in  a  reagent-glass,  is  carefully  covered  with  urine  :  when 
the  coloring-matter  of  the  blood  is  present,  there  is,  besides  the  dirty 
white  deposit  of  resin,  an  indigo-blue  ring.      When  shaken  up,  the 


442  SPECIAL  DIAGNOSIS. 

whole   contents  of  the  glass  become  a  non-transparent  bright  blue. 
The  test  is  a  very  distinct  one. 

(c)  Test  for  hcemin.  This  is  made  with  a  large  drop  of  urine  or 
urinary  sediment,  exactly  in  the  same  way  as  has  been  described 
already  (p.  363)  for  finding  it  in  the  material  vomited.  The  test  is 
more  distinct  than  the  preceding,  particularly  if  we  boil  it  down  in  a 
porcelain  dish  and  then  apply  the  reaction. 

(d)  Spectroscopic  examination.  This  gives  the  absorption-bands 
of  methsemoglobin,  namely,  in  yellow,  green,  and  red.  Of  course, 
this  is  an  extremely  distinct  test. 

Bile-'pigments  and  Bile-acids. 

G-mellins  test  for  hile-pigments.  We  pour  a  small  quantity  of 
nitric  acid  into  a  reagent-glass  and  add  to  it  one  or  two  drops  of 
fuming  nitric  acid,  forming  a  trace  of  an  admixture  of  nitrous  acid. 
To  this  mixture  we  very  cautiously  add  a  layer  of  urine,  by  permitting 
it  to  flow  from  a  pipette,  down  the  side  of  the  glass  held  obliquely. 
When  the  bile-pigment  is  abundant,  if  the  fluids  are  kept  carefully 
distinct,  there  is  a  ring  of  green  (blue),  violet,  and  red.  The  first 
named  constitutes  the  test.  There  is  no  reaction  when  there  is  only 
a  small  amount  of  bile-pigment. 

RosenhacK s  modification  is  decidedly  more  distinct.  Filter  some 
urine,  not  too  little  (about  200  c.cm.),  through  a  medium-sized  filter, 
and  pour  upon  this  the  mixture  of  nitric  and  nitrous  acids.  The 
colored  rings  form  upon  the  filtrate. 

Still  sharper  is  Gmellin's  test,  if,  after  acidulating  the  urine  with 
acetic  acid,  we  shake  it  up  with  chloroform,  pour  off  the  urine,  and 
then  with  the  chloroform,  colored  yellow  by  the  bile-pigment,  make 
a  layer  with  the  nitric-acid  mixture. 

Penzoldt  recommends  a  filtrate  prepared  as  in  the  Gmellin-Rosen- 
bach  test  (allowing  a  good  deal  of  urine  to  flow  through),  over  which 
acetic  acid  is  poured,  and  this  is  allowed  to  flow  into  a  broad  glass 
vessel,  so  as  to  have  it  in  a  shallow,  but  broad,  layer.  The  acetic 
acid  becomes  yellow-green,  gradually  becomes  green  (quicker,  if  it  is 
warmed),  even  bluish-green.  Penzoldt  declares  that  this  test  is  very 
distinct. 

Pettenkofer  s    test  for    bile-acids:     glycocholic,   taurocholic,   and 


EXAMINATION  OF  THE  URINARY  APPARATUS.  44.3 

cholal  acids.  This  test  is  based  upon  the  fact  that  the  addition  of  a 
Aveak  solution  of  cane-sugar  (1  to  500)  and  a  trace  of  concentrated 
sulphuric  acid  to  urine  causes  a  violet-red  color.  We  must  be  care- 
ful not  to  have  the  resulting  elevation  of  temperature  too  high,  at 
most  not  higher  than  about  50°  C. 

For  various  reasons  this  last  reaction  is  uncertain.  Its  result  is 
reliable  only  when  the  bile-acids,  if  present,  have  been  isolated.  At 
any  rate,  the  bile-acids  have  only  a  slight  diagnostic  value :  a  trace 
sometimes  occurs  in  normal  urine,  while  we  find  in  undoubted  cases 
of  jaundice  due  to  engorgement  of  bile,  often  none,  or  only  a  trace, 
because  frequently  in  the  transmission  it  becomes  broken  up  in  the 
blood.  Hence,  Ave  cannot  account  for  the  absence  of  the  bile-acids  in 
the  urine  in  cases  of  icterus  by  the  assumption  that  it  is  not  an 
hepatogenous  icterus.  On  the  other  hand,  an  abundance  of  bile-acids 
in  the  urine  proves  that  the  jaundice  is  due  to  engorgement  of  bile. 
Moreover,  it  is  clear  that  if  we  Avish  to  explain  "  hepatogenous  " 
icterus  by  the  idea  of  engorgement  of  bile  in  the  liver,  logically,  we 
must  assume  an  increase  of  the  bile-acids  in  this  jaundice  also.  As  a 
matter  of  fact,  this  is  found  to  be  the  case  in  toxic  "  hemato-hepato- 
genous''  icterus  (arseniuretted  hydrogen,  toluylendiamin,  Stadelmann). 

Grape-sugar.     Pathologically,  grape-sugar  occurs  in  the  urine : 

1.  In  diabetes  mellitus,  usually  in  considerable  quantity — as  much 
as  tAvo  to  five  per  cent,  (minimum  one-half,  maximum  ten  per  cent.). 
The  urine  is  increased  in  amount,  is  bright  and  clear,  of  higher  specific 
gravity,  as  has  already  been  mentioned. 

2.  As  glycosuria  (Frerichs),  usually  in  small  quantity.  It  is 
almost  always  temporary  after  poisoning  Avith  carbonic  oxide,  curare, 
amyl  nitrite,  turpentine ;  sometimes  with  mercury,  morphia,  chloral, 
prussic  acid,  sulphuric  acid,  alcohol;  again,  in  acute  infectious  dis- 
eases (typhus,  scarlet  fever,  diphtheria,  etc. ;  in  diseases  of  the 
oblongata  (but  here  it  is  more  lasting) ;  and  from  other  neurotic  causes, 
as  excessive  mental  exertion,  neuralgia,  injuries  to  the  central  nervous 
system,  concussion  of  the  brain,  etc. ;  also,  after  epileptic  convulsions 
and  apoplexia  cerebri. 

It  is  to  be  remarked  that  the  urine  is  always  to  be  examined  for 
sugar  when  it  has  a  decidedly  high  specific  gravity  ;  but  particularly 
if  it  is  clear  and  abundant,  and,  at  the  same  time,  has  a  high  specific 
gravity. 


444  SPECIAL  DIAGNOSIS. 

■   Qualitative  Tests  for  Sugar. 

Bismuth  test  (with  Nylander's  modification).  For  this  purpose,  we 
employ  Nylander's  reagent:  2  parts  basic  nitrate  of  bismuth  and  4 
parts  soda  tartrate,  to  100  parts  of  an  8-per  cent,  solution  of  caustic 
soda.  Of  this  we  take  1  part  to  10  of  urine,  and  boil  them  together. 
After  a  few  minutes,  if  there  is  only  a  little  sugar — sometimes  only 
after  it  has  cooled — it  becomes  black  from  the  reduction  of  the 
contents  of  the  reagent-glass  with  the  formation  of  the  oxide  of  bismuth, 
if  the  urine  contains  as  much  as  one  per  cent,  of  sugar. 

It  is  evident  that  this  is  a  very  distinct  test.  It  is  only  uncertain 
when  there  is  albumin  in  the  urine  (arising  from  the  black  sulphuret 
of  bismuth)  ;  here  it  had  better  not  be  employed. 

Trommer  s  test.  To  a  given  quantity  of  urine  we  add  about  one- 
third  as  much  liq.  potassae,  and  to  this,  drop  by  drop,  of  a  10-per-cent. 
solution  of  the  sulphate  of  copper,  as  long  as  it  is  held  in  solution  by 
mixing  ;  then  it  is  heated.  A  precipitate  of  yellowish-red  hydrated 
cupric  suboxide,  which  may  appear  even  before  the  fluid  has  been 
boiled,  shows  the  presence  of  sugar  with  the  greatest  probability.  The 
yellow  color  of  the  liquid,  or  a  precipitate  that  takes  place  later,  may 
be  caused  by  a  very  small  amount  of  sugar,  but  also  by  uric  acid  and 
creatinin.  Thus,  the  test  is  uncertain  when  the  quantity  of  sugar  is 
small ;  hence,  in  brief,  it  is  not  a  sharp  one. 

Pheyiyl-hydracin  test  (von  Jaksch).  About  two  grains  of  muriate 
of  phenyl-hydracin  and  three  of  acetate  of  soda  are  put  into  a  reagent- 
glass  which  is  filled  half-full  of  Avater.  After  heating,  the  glass  is  to 
be  filled  with  the  urine  to  be  tested.  It  is  allowed  to  stand  for 
fifteen  or  twenty  minutes  in  boiling- water,  then  it  is  put  into  a  beaker- 
glass  filled  with  cold  water.  When  there  is  a  large  amount  of  sugar,, 
there  is  formed  a  macroscopically  visible  deposit.  With  a  small 
amount  of  sugar,  after  standing,  there  is  a  deposit,  which  can  be  seen 
with  the  microscope,  of  yellow  needles,  single  and  in  druses — phenyl- 
glucosazon.  Yellow  plates  and  brown  balls  prove  nothing.  Albumin 
that  may  be  present  must  previously  be  removed  by  boiling  the  urine. 

Jaksch  urges  this  test  because  it  is  a  very  exact  one.  Its  difficulty 
consists  in  this,  that  the  needles  of  phenyl-glucosazon  are  sometimes 
not  alike  clearly  characteristic  in  distinction  from  the  yellow  plates, 
etc.,  whi^h  prove  nothing,  these  latter  not  being  crystallizable  in 
alcohol.     Nevertheless,  the  test  seems  to  be  a  very  sharp  one. 


EXAMINATION  OF  THE  URINARY  APPARATUS.  445 

Of  the  other  very  numerous  tests  for  sugar  we  only  mention  the 
following : 

Moore  s  Uq.  pctassoe  and  boiling  test,  which  causes  urine  that  con- 
tains sugar  to  become  brown — not  a  very  certain  and  sharp  test ;  and 
the  test  with  diazo-benzol-sulphuric  acid  and  potash,  recommended  by 
Penzoldt. 

One  test,  of  great  importance  and  highly  recommended  on  account 
of  its  absolute  certainty,  is  somewhat  troublesome  : 

Fermentation  test.  This  rests  upon  the  peculiarity  that  yeast  has 
of  separating  sugar  into  alcohol  and  carbonic  acid  (succinic  acid,  etc.). 
The  test  may  be  made  in  a  simple  way,  as  follows:  Three  perfectly 
clean  reagent-glasses  are  filled  about  two-thirds  full  of  mercury.  The 
first  is  then  to  be  filled  with  some  of  the  urine  to  be  tested  and  a 
little  yeast ;  the  second  is  to  be  filled  with  normal  urine  and  some 
yeast ;  the  third  with  a  thin,  watery  solution  of  sugar  and  yeast.  It 
is  Avell  to  add  to  each  a  drop  of  a  solution  of  tartaric  acid.  All  three 
tubes  are  now  placed  upside  down  in  a  tray  of  mercury,  by  covering 
the  opening  with  the  thumb  as  we  invert  them.  The  second  tube 
should  not  show  any  development  of  carbonic  acid,  but  if  it  should  do 
so  the  yeast  was  not  perfectly  free  from  sugar,  and  the  experiment 
must  be  repeated  with  yeast  that  is  perfectly  pure.  The  third  glass 
should  show  the  development  of  carbonic  acid,  otherwise  the  yeast  has 
become  inactive.  The  first  tube  shows  carbonic  acid  or  not,  accordino; 
to  the  state  of  the  urine  under  examination  in  respect  to  its  containing 
sugar.  The  development  of  carbonic  acid  is  recognized  by  the 
existence  of  gas  in  the  upper  part  of  the  inverted  tube.  Its  presence 
is  made  certain  by  its  being  absorbed  when  potash-lye  is  introduced 
into  the  tube. 

Fermentation-tubes  are  very  helpful  in  employing  the  fermentation 
test  (see  Salkowski-Leube,  Penzoldt). 

Quantitative  Determination  of  Sugar. 

This  is  indispensable,  if  a  case  of  diabetes  is  to  be  carefully  observed, 
particularly  for  determining  its  severity,  its  course,  especially  the  effect 
of  treatment.  From  the  qualitative  examination  we  cannot  draw  satis- 
factory conclusions  as  to  the  amount  of  sugar,  except  by  a  comparison 
of  the  specific  gravity  of  the  urine  with  its  quantity. 

We  make  use  of  the  urine  that  is  passed  in  exactly  twenty-four  hours. 


446  SPECIAL  DIAGNOSIS. 

1.  Estimating  it  tvith  Fehling's  solution  (after  Salkowski-Leube,. 
Penzoldt).  The  principle  is  that  in  Trommer's  test,  the  oxide  of 
copper  in  an  alkaline  solution  of  grape-sugar  is  reduced  to  a  lower 
state  of  oxidation  :  five  parts  of  anhydrous  grape-sugar  will  reduce 
34,639  parts  of  pure  sulphate  of  copper  to  protoxide.  The  problem  is 
to  determine  how  much  of  a  specimen  of  urine  is  necessary  to  reduce 
a  certain  amount  of  sulphate  of  copper. 

Solution  I.  34,639  grammes  of  pure  sulphate  of  copper  are,  by 
warming,  dissolved  in  about  100  grammes  of  water,  and  the  solution 
is  then  diluted  to  500  c.c.     It  is  to  be  set  away  well  corked. 

Solution  II.  173  parts  of  tartrate  of  soda  and  100  parts  of  officinal 
solution  of  caustic  soda  of  the  specific  gravity  of  1034,  dissolved  in 
water  to  500  parts.  This  is  to  be  kept  in  a  well-stoppered  bottle  \. 
but  it  must  not  be  allowed  to  become  too  stale. 

Mode  of  procedure:  Equal  parts  of  I.  and  II.  are  mixed  together. 
The  mixture  (Fehling's  solution)  must  not,  when  boiled,  separate  any 
oxydul.  10  c.c.  of  the  mixture  and  40  c.c.  of  water  are  placed  in 
a  deep  porcelain  saucer.  Thoroughly  mixing  the  urine  of  twenty -four 
hours,  we  take  a  portion  of  this  and  dilute  it  with  9  parts  of  water 
(urine  1,  water  9),  and  with  this  we  fill  a  burette.  The  mixture  in 
the  saucer  is  brought  to  the  boiling-point,  and  into  this  the  urine  in 
the  burette  is  allowed  to  flow :  there  occurs  a  separation  of  oxydul 
and  oxydul-hydrate,  and  the  blue  color  of  Fehling's  solution  disap- 
pears. The  instant  when  the  fluid  (if  we  incline  the  saucer)  first 
loses  its  color,  shows  the  completion  of  the  reduction.  We  allow  the 
amount  of  urine  necessary  to  complete  the  reduction  to  flow  from  the 
burette. 

Calculation:  Since  0.05  gramme  of  grape-sugar  reduces  10  c.c. 

of  Fehling's  solution,  therefore  the  quantity  of  the  mixture  which  has 

escaped  from  the  burette  contained  0,05  gramme  of  grape-sugar     We 

represent  that  quantity  of  the  mixture  by  "  ^,  "  then  the  mixture  in 

0.05  X  100       5 

the   burette    contains   =  -   per    cent,    of  sugar.      And, 

q  q 

since  the  mixture  of  urine  was  diluted  tenfold,  the  urine  itself  contains 

5  X  10       50 

=  —  per  cent,  sugar — that  is,  5  times  the  amount  diluted, 

divided  by  the  quantity  of  the  mixture  in  the  burette  that  was  used. 


EXAMINATION  OF  THE  URINARY  APPARATUS.  447 

The  dilution  of  the  urine  is  to  be  varied  according  to  the  amount  of 
sugar  it  contains. 

2.  Determining  "the  sugar  by  circumpolarization.  This  depends 
upon  the  property  of  sugar  to  turn  the  plane  of  polarization  to  the 
right.  Recently,  the  method  has  come  somewhat  into  discredit,  or  it 
has  been  shown  to  be  exact  only  when  Ave  exclude  oxybutyric  acid  and 
any  levulose  that  may  be  present  (which,  according  to  Kulz,  some- 
times occurs  in  severe  forms  of  diabetes).  Regarding  complicated 
methods  (complete  fermentation,  etc.),  see  hand-books  upon  Urinary 
Analysis. 

We  do  not  give  a  description  of  the  method  by  polarization,  as  a 
description  of  its  use  always  accompanies  the  different  apparatus  sold. 
(We  recommend  particularly  the  simple  apparatus  made  by  Zeiss.) 

Other  Soluble  Constituents  of  the  Urine. 

Levulose  sometimes  occurs  in  the  urine,  in  addition  to  grape-sugar, 
in  cases  of  diabetes  mellitus.  It  gives  the  chemical  reaction  of  the 
latter,  and  for  this  reason  it  cannot,  without  complicated  methods,  be 
recognized,  chiefly  on  account  of  a  striking  difference  between  the 
quantitative  determination  by  Fehling's  solution,  on  the  other  side, 
and  the  polarizing  apparatus  on  the  other.  Levulose  turns  it  to  the 
left;  but  Ave  must  be  on  guard  with  reference  to  oxybutyric  acid. 

Lactose,  occurring  in  puerperal  patients,  inosite  in  diabetes  in- 
sipidus, albumin,  can  only  be  demonstrated  in  the  urine  when  they 
are  isolated. 

Lipuria,  as  has  been  already  mentioned,  occurs  in  chyluria.  It 
has,  in  one  instance  (Ebstein),  been  found  in  pyonephrosis;  small 
quantities  of  fat  occur,  with  large  Avhite  kidney  (see  Sediments),  in 
poisoning  by  phosphorus,  and  in  diabetes  mellitus,  but  also  in  health 
after  taking  very  much  fat,  as  cod-liver  oil.  The  proof  is  by  shaking 
it  up  Avith  ether.  Lapaciduria  (fugitive  fatty  acids  in  the  urine)  has 
recently  been  much  studied,  but  thus  far,  from  the  standpoint  of 
diagnosis,  Avithout  significance. 

Diaceturia,  resulting  from  acetoacetic  acid  in  the  urine  (Jaksch), 
never  occurs  under  physiological  conditions.  It  is  observed 
(always  Avith  a  simultaneous  abundance  of  acetone,  see  below) 
in  diabetes,  and  especially  in  the  severe  forms,  which  then  some- 
times end  in  coma ;  also  in  fever  and  as  an  independent  dis- 
ease (Jaksch) ;  and  both  are  apt  to  occur  in  children.     Diaceturia 


448  SPECIAL  DIAGNOSIS. 

is  o-enerally,  especially  if  it  occurs  in  adults,  associated  with  severe 
symptoms,  particularly  nervous,  -wliicli  are  to  be  regarded  as  signs 
of  auto-intoxication  [poisoning]  ;  hence  it  may  result  in  deep  coma 
and  be  the  direct  precursor  of  death.  As  to  its  significance  when 
it  occurs  in  children,  Jaksch,  by  recent  investigations,  arrives  at 
the  supposition  that  the  convulsions  which  so  frequently  occur 
with  them  in  acute  diseases   are  explained  by  diaceturia. 

Test.  Some  solution  of  chloride  of  iron  is  slowly  added  to  the 
urine  ;  sometimes  there  occurs  a  precipitate  of  phosphates,  which 
must  be  removed  by  filtration ;  then  more  iron  chloride  must  be  added. 
If  glacial  acetic  acid  is  present,  the  urine  becomes  a  Bordeaux-red. 
Then  the  test  must  be  repeated  v/ith  urine  that  has  been  boiled. 
Further,  a  poition  of  urine  must  be  mixed  with  sulphuric  acid,  ex- 
tracted with  ether  and  repeated  with  the  extract ;  lastly,  it  must  be 
examined  for  acetone  (see  below).  Diaceturia  is  present  if,  in  the 
presence  of  the  chloride-of-iron  reaction  of  the  fresh  urine,  1,  tbe 
boiled  urine  shows  no,  or  only  a  slight,  chloride  of-iron  reaction  ;  2, 
if  the  ether  extract  shows  a  chloride-of-iron  reaction  which  fades  in 
the  course  of  twenty-four  hours  at  the  longest ;  3,  if  acetone  is  present 
at  the  same  time  (Jaksch). 

Acetonuria,  in  contradistinction  from  the  preceding,  is,  it  seems,  in 
most  cases  a  phenomenon  without  significance.  It  occurs  in  health  (a 
trace),  in  fever,  in  diabetes,  with  inanition,  but  also  Avithout  these  in 
carcinoma,  in  psychoses.  There  also  seems  to  be  an  auto-intoxication 
[poisoning]  with  acetone  (v.  Jaksch),  which  accompanies  symptoms 
of  cerebral  irritation  (also  epileptic  convulsions),  states  of  depression. 
The  cases  hitherto  observed  have  ended  in  recovery.  Thus,  an 
abundance  of  acetone  is  found  in  the  urine,  but  no  glacial  acetic  acid 
(see  above). 

The  exact  test  is  complicated.  Several  methods  have  been  given, 
which,  if  one  wishes  to  be  certain,  it  is  best  to  employ  simultaneously  : 
1.  Distil  the  urine  with  some  phosphoric  acid.  Several  cubic  centi- 
metres of  this  distillate  are  mixed  with  a  few  drops  of  solution  of 
iodine  and  iodide  of  potassium  ;  an  immediate  precipitate  of  iodoform- 
crystals  proves  acetone  (Lieben).  2.  We  add  to  the  urine  some 
freshly-prepared  oxide  of  mercury,  obtained  by  mixing  :in  alcoholic 
solution  of  potash  with  chloride  of  mercury.  Filter  it,  and  cover  the 
filtrate  with  sulphate  of  ammonium  :  a  black  ring  of  sulphate  of  mer- 
cury shows  acetone  (Reynolds).      Legal  (cited  by  Jaksch)  has  devised 


EXAMINATION  OF  THE  URINARY  APPARATUS.  449 

a  test  for  acetone  which  is  a  useful  preliminary  one :  Several  cubic 
centimetres  of  urine  are  treated  with  a  few  drops  of  a  concentrated 
solution  of  sodium  nitroprusside  and  somewhat  concentrated  liquor 
potassae.  If  acetone  be  present,  a  bright  red  color  is  seen,  which 
quickly  fades,  but  upon  the  addition  of  some  acetic  acid  changes  to 
purple  or  violet-red. 

Acetone  is  a  product  of  normal  decomposition  of  albumin.  If  this 
body  is  abundant  in  the  urine  it  indicates  an  increased  decomposition 
of  albumin.  It  is  worthy  of  note  that  acetic  acid  easily  breaks  up 
into  acetone  and  carbonic  acid,  and  that  acetic  acid,  in  turn,  is  a 
product  of  oxidation  of  /3-oxybutyric  acid.  This  acid  is  found  in 
diabetic  coma,  as  it  seems,  exceptionally  in  very  large  quantities  in 
the  urine  (Stadelmann,  Minkowski) ;  and  it  becomes  more  and  more 
probable  that  it,  in  union  with  other  fatty  acids,  must  be  regarded  as 
the  cause  of  diabetic  coma,  as  the  pupils  of  Naunyn,  mentioned 
above,  have  for  years  maintained.  Hence,  in  diabetic  coma  we  have 
to  deal  with  an  acid-intoxication  of  the  organism,  in  which  it  is  to  be 
assumed  that  the  given  acids  only  as  acids  are  poisonous — that  is, 
by  the  withdrawal  of  alkalies  from  the  blood. 

In  close  relation  with  the  withdrawal  of  the  acids  stands  (according 
to  Hallervorden,  Stadelmann)  the  separation  of  a  substance  with 
which  the  organism,  as  long  as  possible,  attempts  to  neutralize  the 
pernicious  acids  :  the  separation  of  ammonia  in  the  urine.  We  cannot 
go  into  the  subject  here,  for  the  reason  that  the  quantitative  deter- 
mination of  ammonia  does  not  come  within  the  province  of  this  work. 

[The  Translator  adds  here  a  summary  of  Stadelmann's  observations 
upon  "Diabetic  Coma,"  as  given  in  i\\e  American  Journal  of  the 
Medical  Sciences,  taken  from  Deutsch.  med.  Wochenschrift,  1889, 
No.  46  : 

"  1.  Diabetic  coma,  apart  from  accidental  coma  due  to  other  causes, 
occurs  only  in  the  case  of  diabetic  patients  whose  urine  contains 
oxybutyric  acids. 

"  2.  Almost  equivalent  in  value  with  the  recognition  of  oxybutyric 
acid  is  the  determination  of  the  amount  of  ammonia  in  the  urine ; 
while  it  is  also  far  easier  of  performance. 

"  3.  Diabetic  patients  with  an  excretion  of  ammonia  of  more  than 
one  and  one-tenth  grammes  per  day,  are  in  danger  of  becoming 
severe  cases  of  the  disease. 

29 


450  ■  SPECIAL  DIAGNOSIS. 

"  4,  Patients  excreting  two,  four,  six,  and  more  grammes  of  am- 
monia daily,  need  constant  watching  by  the  physician,  and  are  in 
constant  danger  of  passing  into  diabetic  coma. 

"5.  If  the  determination  of  the  presence  of  oxy butyric  acid,  or  the 
estimation  of  the  amount  of  ammonia,  cannot  be  carried  out,  at  least 
the  chloride-of-iron  test  should  be  made.  If  this  gives  a  more  positive 
reaction,  oxybutyric  acid  is  present  in  the  urine,  and  the  cases  answer 
to  the  statements  made  in  the  third  and  fourth  conclusions.  The 
converse  of  this,  however,  is  not  always  true,  for  there  are  cases  of 
diabetes  with  oxybutyric  acid  in  the  urine,  and  even  suffering  from 
diabetic  coma,  the  urine  of  which  does  not  give  the  chloride-of-iron 
reaction."] 

Regardmg  the  occurrence  of  the  two  compounds  of  sulphuric  acid 
or  of  the  products  of  their  decomposition  (here  also  belong  indican, 
which  has  been  previously  mentioned,  indoxylsulphuric  acid),  also  of 
ptomaines,  ferments  (especially  pepsin),  see  the  various  special  works 
upon  these  subjects. 

The  Urine  as  Affected  hy  Medicines. 

The  determination  as  to  whether  a  medicine  has  been  taken  or  not 
may  often  be  of  diagnostic  importance.  A  number  of  medicines  may 
be  directly  detected  in  the  urine;  to  those  not  easily,  or  not  at  all, 
demonstrable  to  a  slight  extent,  according  to  Penzoldt's  recommenda- 
tion of  a  particular  case,  we  can  add  one  easily  demonstrable. 

If  we  find  in  the  urine  the  reaction  of  demonstrable  medicines  that 
have  been  given,  then  we  can  naturally  assume  that  any  other  which 
was  mixed  with  it  has  been  taken. 

Iodide  of  potassium.  Add  a  couple  of  drops  of  red  fuming  nitric 
acid  and  about  one-quarter  as  much  chloroform  as  there  is  of  urine ; 
shake  it ;  the  chloroform  gradually  settles  down,  colored  reddish- 
violet. 

Bromine.     The  same  method ;  chloroform  colors  it  brown-yellow. 

Salicylic  acid.  The  urine  is  made  a  blue-violet  by  the  chloride  of 
iron  (not  Burgundy-red,  see  Diaceturia).  When  the  amount  of  sali- 
cylic acid  is  small,  we  shake  up  the  urine  (to  which  some  sulphuric 
acid  has  been  added)  with  ether  and  then  apply  the  test. 

Rhubarb  and  senna,  see  p.  411. 


EXAMINATION  OF  THE  URINARY  APPARATUS.  45I 

Carbolic  acid,  also  yiaphthalin,  resorcin,  etc.  Upon  standing,  the 
urine  becomes  olive-green  to  brown-black,  even  black  (hydrochinon). 
Exact  determination  requires  particular  methods. 

Salol.  Urine  containing  this,  as  well  as  carbolic  acid,  becomes 
green  to  black,  and,  at  the  same  time,  responds  to  the  tests  for  sali- 
cylic acid. 

Antifehrin.  Add  one-fourth  volume  of  a  concentrated  solution  of 
hydrochloric  acid  in  a  reagent-glass ;  boil  for  a  few  minutes ;  cool ; 
add  a  few  c.c.  of  a  three-per-cent.  solution  of  carbolic  acid  and  a  drop 
of  dilute  solution  of  chromic  acid.  The  mixture  becomes  red  ;  after 
the  addition  of  ammonia  up  to  an  alkaline  reaction,  a  beautiful  blue. 
(After  Miiller.) 

Antipyrin,  thallin.  Red  coloration  with  chloride  of  iron;  more- 
over, thallin  urine  is  green-brown. 

Works  upon  Chemical  Analysis  and  Toxicology  give  further 
information. 


CHAPTER    YIII. 

EXAMINATION  OF  THE  NERVOUS  SYSTEM. 

Anatomy;   Normal  and  Pathological  Physiology. 

Only  a  sketch  of  what  is  most  important  can  be  given  here.     For 
further  particulars,  see  the  special  text-books  upon  the  subject. 

1.  THE  CORTICO-MUSCULAR  TRACT  (tHE  PYRAMIDAL  TRACT,  FLECHSIG). 

It  has  its   origin  in  the   so-called  psycho-motor    centres   of  the 
cortical  substance  of  the  cerebrum.     These  lie  in  the  motor- cortical 

Fig.  139. 

^^.X^-obuhis  paracsTifralis 


Lateral  view  of  the  brain.     (Combined  from  Ecker.)     Gyri  and  lobuli  marked  with, 
antique  type,  the  sulci  and  fissures  with  italic  type. 
(452) 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  453 

Fig.  140. 


Diagram  of  the  motor  tracts  of  tbe  facial  nerve  and  of  the  nerves  of  the  extremities. 
(Edinger.)  At  a,  B,  C,  are  ind.cated  supposed  local  diseases.  ^^  lesion  of  the  left 
side  of  the  internal  capsule,  causing  right  hemiplegia  on  the  right  sidej  B,  lesion  of 
the  left  half  of  the  pons,  touches  the  pyramidal  tract  of  the  extremities  of  the  right  side 
and  of  the  left  facial,  causing  crossed  paralysis;  C,  shows  the  rare  condition  of  uncrossed 
facial  paralysis  and  paralysis  of  the  extremities  from  lesion  in  the  pons. 


454 


SPECIAL  DIAGNOSIS. 


Fig.  141. 


region,  which  includes  the  anterior  and  posterior  central  convolutions 
and  the  lobus  paracentralis  of  each  hemisphere.     It  has  been  found 

that  the  centre  for  the  lower  portion 
of  the  face  (the  countenance,  exclud- 
ing the  forehead),  and  the  tongue,  is 
from  the  lower  section  of  the  anterior 
rather  than  the  posterior  central  con- 
volution. 

The  centre  for  the  arm  is  in  the 
middle  portion  of  the  anterior  central 
convolution. 

The  centre  for  the  leg  is  in  the 
lobus  paracentralis  and  the  upper 
section  of  both  central  convolutions. 

Thus,  the  centres  of  the  cortex  lie 
tolerably  wide  apart. 

The  tracts  course  from  there,  and 
next  converge  in  the  corona  radiata, 
in  a  fan-shape,  to  the  internal  capsule, 
Avhere  they  lie  close  together  in  its 
anterior  segment,  hence  between  the 
lenticular  nucleus  and  optic  thalamus. 
They  lie  close  behind  a  point  midway 
between  these  [but  do  not  connect 
with  them].  From  thence  they  go  to 
the  foot  of  the  crus  cerebri,  passing 
about  in  the  middle  of  it.  In  the 
pons,  the  pyramidal  tracts  are  split 
up  by  transverse  fibres.  They  unite 
again  to  form  pyramids  at  the  an- 
terior portion  of  the  medulla  ob- 
longata, and  here  the  pyramidal 
tracts  of  the  two  sides  lie  very  close 
together.  [From  the  circumstance 
that  they  form  the  anterior  pyramids 
of  the  medulla,  they  receive  their 
name,  "  pyramidal  tracts,"]  At  the 
lower  end  of  the  medulla  the  right 


Diagram  of  the  innervation  of  the 
muscles.  (Partly  from  Edinger.) 
The  radiation  of  the  Py-tracts  varies 
at  different  portions  of  the  cortex 
(see  p.  452).  JPy-H,  pyramidal  tract 
for  the  cervical  spinal  cord ;  Py-L, 
pyramidal  tract  for  the  lumbar  por- 
tion of  the  cord  ;  H,  cervical  cord  ; 
L,  lumbar  cord;  Py-Fis  omitted. 
Notice  that  down  to  the  lumbar  por- 
tion of  the  cord  Py-L  passes  in  the 
lateral  column. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 


455 


and  left  pyramidal  tracts  interlace,  so  that  very  mucli  the  larger  part 
of  the  fibres  go  to  foi"m  the  lateral  column  of  the  opposite  side  of  the 
spinal  cord  (lateral  pyramidal  tract).  Only  a  small  part  of  the  fibres 
[of  the  external  aspect  of  the  pyramids],  without  crossing  to  the 
opposite  side,  pass  to  the  anterior  column  of  the  spinal  cord  [forming 
the  columns  of  Tiirck].     (Anterior  pyramidal  tracts,  Pi/-  V.) 

At  different  levels  of  the  cord,  from  the  lateral  pyramidal  tracts, 
fibres  continually  pass  to  the  ganglion  cell-groups  of  the  same  side, 
and  from  these  ganglion  cells  arise  the  anterior  roots  of  the  [nerves 
of  the]  spinal  cord.  These  unite  with  the  posterior,  and  form  with 
them  the  mixed  peripheral  nerves.  In  these  the  motor  tracts  pass  to 
the  muscles. 

The  tracts  for  the  motor  cranial  nerves  separate  successively  in  the 
pons  and  oblongata  from  the  pyramidal  tracts,  decussate  and,  at  the 
floor  of  the  fourth  ventricle,  enter  the  grey  nuclei  of  the  pons  and 
oblongata,  which  consist  of  ganglion  cells,  perfectly  analogous  to  the 
anterior  horn  ganglia. 


Fig.  142. 


Tsir.   m.  w.  

Location  of  the  nuclei  of  the  cranial  nerves.  fEoiNGER.)  The  oblongata  and  pons 
are  represented  as  transparent.  The  nuclei  of  sensation  are  red,  the  motor  are 
black. 


The  centres  of  the  cortex  are  those  of  voluntary  motion ;  the 
centres  of  the  anterior  horns  simply  convey  these  to  the  peripheral 
nerves.  Moreover,  they  are  the  reflex  spinal  centres,  in  that  they 
receive  sensible  irritation  from  the  posterior  roots  of  the  spinal  cord 


456  ■     SPECIAL  DIAGNOSIS. 

(see  below)  and  transpose  them  into  motor  stimuli,  which  they  convey 
to  the  anterior  roots. 

But  both  central  apparatuses  also  have  trophic  influences — that  is, 
they  preside  over  the  nutrition  of  a  certain  section  of  the  cortico- 
muscular  tract.  The  cortical  centres  preside  over  the  nutrition  of  the 
fibres  until  they  enter  the  ganglia  of  the  anterior  horn.  These  latter 
control  the  nutrition  of  the  peripheral  nerve-fibres  and  of  the 
muscles. 

Paralysis  is  produced  by  any  lesion  (local  disease :  hemorrhage, 
softening,  inflammation,  tumor)  at  any  point  in  the  cortico  muscular 
tract  which  disturbs  the  central  ganglia  or  interrupts  the  course  of 
the  tract.  According  to  the  location  of  the  lesion,  this  paralysis 
shoAvs  difierent  characteristics ;  and  these  may  primarily  be  studied 
from  three  points  of  view : 

1.  If  the  lesion  is  located  in  the  cortex,  or  afiects  the  tracts  above 
the  point  of  decussation,  then  the  paralysis  is  upon  the  opposite  side 
of  the  body ;  on  the  contrary,  lesion  below  the  decussation  produces 
paralysis  of  the  same  side.  If  located  in  the  pons,  it  may  happen, 
for  example,  that  besides  the  pyramidal  tract,  which  as  yet  has  not 
decussated,  it  affects  the  fibres  of  the  facial,  which  have  already 
crossed  over  (see  above),  it  then  causes  paralysis  of  the  opposite  side 
of  the  body  and  of  the  same  side  of  the  face,  hence  these  two  cross 
each  other — hemiplegia  cruciata  seu  alter ans. 

2.  If  the  lesion  affects  a  cortical  centre,  or  a  point  in  the  pyramidal 
tract  in  the  brain,  the  pons,  the  oblongata,  the  spinal  cord  above  the 
point  of  entrance  of  the  particular  tract  into  ganglia  of  the  anterior 
horn  (or  the  analogous  gray  nuclei  of  the  oblongata  or  of  the  pons), 
then,  because  the  trophical  influence  of  the  cortical  centre  from  above 
ceases  at  that  point,  the  affected  tract  degenerates  just  up  to  the  cor- 
responding cells  of  the  anterior  horn,  while  these  and  the  peripheral 
nerves  and  the  muscles  do  not  desienerate.  This  degeneration  of  the 
pyramidal  tract  does  not  in  itself  cause  any  further  clinical  phe- 
nomena. On  the  other  hand,  if  the  lesion  is  in  the  anterior  horn,  or 
downward  from  there  in  the  motor  tract,  there  is  degeneration 
downward  of  the  nerves  and  muscles  supplied  by  the  portion  which  is 
the  seat  of  the  lesion.  In  the  latter  case,  we  have  the  clinical  evi- 
dences of  degeneration  (rapid  diminution  in  volume,  diminution  or 
loss  of  electrical  reaction,  and  other  signs  of  degeneration,  see  below). 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  457 

3.  Since  the  centres  and  tracts  in  the  different  sections  in  some 
instances  lie  wide  apart  and  in  others  close  together,  a  certain  extent 
of  lesion,  according  to  its  location,  will  cause  a  paralysis  widely 
different  in  its  extent : 

(a)  A  lesion  of"  considerable  extent  located  in  the  cortex,  or  in  the 
corona  radiata,  just  under  it,  generally  affects  the  centre  for  one-half 
of  the  countenance,  or  an  arm,  or  a  leg  (monoplegia). 

{h)  If  located  in  the  internal  capsule,  then  the  lesion  need  not  be 
so  very  large  in  order  to  produce  a  paralysis  of  the  whole  of  the 
opposite  side  of  the  body — hemiplegia.  This  points  to  the  crus 
cerebri. 

(c)  If  the  lesion  is  in  the  cord,  where  the  motor  organs  and  all 
the  other  nervous  organs  of  the  body  lie  close  together,  it  easily 
causes  paralysis  of  both  sides  :  thus,  lesion  of  the  dorsal  portion  of 
the  cord  produces  paralysis  of  both  lower  extremities,  or  paraplegia 
inferior ;  lesion  of  the  cervical  portion  of  the  cord  sometimes  causes 
paralysis  of  both  arms  and  both  legs,  or  only  the  former — paraplegia 
superior  seu  brachialis. 

To  the  above  statements  we  may  add  still  another : 

(d)  If  the  lesion  is  in  the  pons  and  oblongata,  it  may  easily  affect 
to  a  considerable  degree  the  centres  that  are  very  essential  to  life, 
as  the  respiratory-centre,  vagus-centre  for  the  heart,  and  death  may 
soon  follow.  Often,  if  there  is  hemorrhage  or  softening,  it  may  take 
place  immediately. 

A  local  disease  at  the  base  of  the  brain  injures  the  cranial  nerves 
wliich  go  off  from  that  point.  If  it  is  located  in  the  anterior 
cranial  fossa,  the  olfactory  nerve  will  be  affected ;  if  in  the  middle 
cranial  fossa,  it  may  cause  disease  of  the  opticus,  oculomotorius, 
trochlearis,  abducens,  sometimes  also  the  olfactorius ;  if  in  the 
posterior  fossa,  the  trochlearis,  abducens,  facialis,  acusticus,  glosso- 
pharyngeus,  vagus,  accessorius,  come  under  consideration.  The 
disease  may  be  bilateral.  See  the  illustration,  which  shows  how  the 
different  nerves  come  together  at  the  base  of  the  skull.  From 
simultaneous  injury  to  the  crus  cerebri,  pons,  and  oblongata,  the 
pyramidal  tracts  may  become  affected,  and  paralysis  of  the  extremi- 
ties results.  In  basilar  affections,  this  is  generally  less  marked  than 
is  the  paralysis  of  the  cranial  nerves. 


458 


SPECIAL  DIAGNOSIS. 


The  foregoing   contains    only   the    introduction   to   the  points   of 
diagnosis  in  these  directions.      "We  must  refer  for  particulars  to  the 


Fig.  T43. 


Points  of  exit  of  the  cranial  nerves  from  the  skull.  (Henle.)  The  Roman  figures 
indicate  the  cranial  nerves;  Vi,V2,  V^,  fi.rst,  second,  and  third  branches  of  the  tri- 
geminus; V*,  Gasserian  ganglion. 


clinical  text-books.     AYc  refer  here  to  text-books  upon  clinical  medi- 
cine, and  particularly  to  the  second  edition  of  Edinger's  book  on  the 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  459 

Struetnre  of  the  Central  Organs  of  the  Nervous  System,  the  second 
edition  of  which  has  just  appeared. 

2.    THE    SENSITIVE    OR    CENTRIPETAL    TRACTS. 

The  tract  of  the  sensibility  of  the  skin  of  the  trunk  and  of  the 
extremities  passes  from  the  sensitive  terminal  fibres  of  the  skin  in  the 
mixed  nerves,  then  into  the  posterior  root  to  the  cord.  From  there 
it,  for  the  most  part,  enters  the  posterior  horn  (it  is  doubtful  whether 
a  small  portion  may  not  enter  the  lateral  column) ;  it  decussates  soon 
after  its  entrance  into  the  cord — how,  we  do  not  know.  Above  the 
cord  we  do  not  know  the  behavior  of  this  tract  till  it  reaches  the 
tegumentum  cruris  cerebri,  into  Avhich  it  passes.  Then  it  enters  the 
inner  capsule  behind  the  pyramidal  tract — that  is,  in  the  posterior 
third  of  the  posterior  peduncle.  Beyond  this,  we  do  not  exactly 
know  its  course. 

The  tract  of  deep  sensibility  (usually  called  the  muscular  sense) 
probably  has  the  same  course  as  that  we  have  just  described.  Most 
probably  it  ends  in  the  motor  cortical  zone  of  the  central  convolutions 
and  the  lobus  paracentralis. 

An  important  centripetal,  but  not  in  the  strict  sense  a  sensitive, 
tract,  are  the  columns  of  Goll,  which  likewise  arise  from  the  posterior 
roots,  which,  moreover,  only  from  the  upper  part  of  the  dorsal  portion 
of  the  cord,  and  above  that  point,  form  a  compact  bundle  in  the 
median  portion  of  the  posterior  column.  We  know  nothing  positive 
of  their  function.  Also,  the  lateral  column  of  the  tract  of  the  cere- 
bellum is  centripetal,  which,  in  the  upper  portion  of  the  cord, 
springing  from  the  columns  of  Clarke,  goes  into  the  cerebrum.  Its 
function,  also,  is  not  entirely  clear ;  probably  it  is  of  service  in 
preserving  equilibrium. 

Severe  lesions,  or  complete  interruption  of  the  tract  of  sensibility  of 
the  skin  in  the  peripheral  nerves,  or  in  the  cord,  or  in  the  internal 
capsule,  cause  total  anaesthesia  of  the  skin.  If  the  lesion  is  not 
severe,  there  is  diminution  of  the  sense  of  touch  or  a  partial  loss  of 
sensibility — a  partial  paralysis  of  sensibility,  as  the  sense  of  pain — 
and  this  latter  is  frequent,  especially  in  disease  of  the  spinal  cord. 
Anaesthesia  from  local  disease  of  the  internal  capsule,  or  of  the  spinal 
cord,  manifests  itself  upon  the  opposite  side. 


460 


SPECIAL  DIAGNOSIS. 


3.    CENTRES    AND    TRACTS    OF    THE    SPECIAL    SENSES. 

(a)  Sight.  This  tract  passes  from  the  retina  in  the  eye  to  the 
chiasm.  Here  occurs  a  peculiar  partial  decussation  (semi- decussation), 
which  is  reproduced  in  Fig.  144 :  the  optic  nerve-fibres  belonging  to 
the  outer  half  of  the  retina  do  not  cross,  those  belonging  to  the  inner 
half  do.  Then  it  passes  in  the  optic  tract  to  the  anterior  corpus 
quadrigeminum,  and  from  there  in  the  posterior  third  of  the  posterior 
limb  of  the  internal  capsule  entering  into  relation  with  the  pulvinar 
of  the  optic  thalamus  and  the  corpus  geniculum  ext.,  and  then  spreads 
out  obliquely  backward  and  upward  in  the  cortex  of  the  occipital  lobe. 
The  most  important  points  in  relation  to  this  nerve  are  the  following : 


Fig.  144. 


Diagram  of  the  optic  nerve-fibres  in  the  chiasm. 

1.  That  pathological  processes  at  the  base  of  the  brain,  and  lesions 
in  the  posterior  end  of  the  inner  capsule  (causing  a  simultaneous  hemi- 
ansesthesia),  of  the  pulvinar  of  the  optic  thalamus,  or  of  the  occipital 
lobe,  produce  disturbances  of  vision. 

2.  That  every  complete  destruction  of  the  cortical  centres  in  the 
occipital  lobes,  as  well  as  of  the  tract  from  there  to  the  chiasm,  cuts 
off  the  impressions  of  sight  from  the  outer  half  of  the  retina  of  the 
same  side  and  the  inner  half  of  the  opposite  side,  thus  from  synony- 
mous halves  of  the  two  retinae.  Thus,  hemiopia  and  hemianopsia  are 
produced  (see  under  Eye). 

(b)  Hearing.     The  acoustic  nerve  passes,  together  with  the  facial, 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  4(U 

to  the  oblongata,  to  the  acoustic  ganglion,  in  regard  to  which,  we 
cannot  here  enter  into  further  detail.  In  its  central  course  it  comes 
into  relation  with  the  cerebrum,  and  then  appears,  probably,  in  the 
most  posterior,  sensitive  portion  of  the  internal  capsule,  whence  it 
spreads  out  in  the  cortex  of  the  temporal  lobe  (see  Word-deafness). 

((')  Smell.  Of  the  olfactory  nerve  perhaps  nothing  more  is  to  be 
said  than  that  its  centripetal  tract  seems  to  pass  through  the  posterior 
portion  of  the  internal  capsule. 

(d)  Taste.  The  sense  of  taste  is  located  [chiefly]  in  the  glosso- 
pharyngeus  nerve,  distributed  to  the  palate  and  the  posterior  third  of 
the  tongue,  by  which  nerve  it  is  conveyed  to  the  oblongata.  The 
course  for  the  anterior  two-thirds,  however,  is  complicated:  as  the 
chorda  tympani,  it  first  passes  in  the  lingual  nerve,  but  leaves  tliis 
and  goes  to  the  facial,  leaves  this  again  at  the  geniculate  ganglion,  and 
probably  extends,  as  the  greater  superficial  petrosal  nerve,  Vidian,  and 
the  sphenopalatine  ganglion,  to  the  trigeminus  (second  branch),  going 
toward  the  centre  with  this.  We  again  meet  the  fibres  of  taste  in  the 
posterior  portion  of  the  inner  capsule. 

It  is  very  important  to  note  the  participation  of  the  sense  of  taste 
at  the  anterior  portion  of  the  tongue  in  peripheral  paralysis  of  the 
facial,  and  also  (according  to  Erb  and  others)  in  disease  of  the  tri- 
geminus situated  high  up,  as  well  as  in  lesions  of  the  posterior  portion 
of  the  inner  capsule  (hemisesthesia). 

Until  we  come  to  the  symptomatology,  we  delay  speaking  of  all 
other  points  regarding  localization  of  the  brain,  especially  regarding 
aphasia  and  the  phenomena  associated  with  it,  and  regarding  the 
origin  of  certain  forms  of  convulsions,  of  vertigo,  coordination,  etc. 

4.    REMARKS    UPON    THE    VESSELS    SUPPLYING   THE    BRAIN. 

The  brain  is  supplied  with  blood  from  the  two  internal  carotids  and 
from  the  vertebral  artery.  The  right  and  left  vertebral  unite  at  the 
basilar  surface  of  the  pons  to  form  the  basilar  artery ;  this,  again, 
divides  at  a  point  corresponding  to  the  anterior  inferior  border  of  the 
pons  into  the  two  posterior  cerebral  arteries,  which,  by  the  posterior 
communicating  arteries,  form  a  connection  with  the  carotids  (the  circle 
of  Willis).  Besides  the  ophthalmic  and  the  posterior  communicating, 
the  carotid  gives  off  the  anterior  communicating,  which,  with  its 
opposite  fellow,  completes  the  circle  of  Willis.     There  also  arises  from 


462  SPECIAL  DIAGNOSIS. 

the  carotid  the  middle  cerebral,  the  [hirgest,  and]  most  important 
vessel  of  the  brain. 

Of  tliese  vessels  the  greatest  interest  attaches  to  those  which  supply 
the  pons  and  medulla,  and  the  most  important  part  of  the  cortex  and 
the  internal  capsule. 

The  pons  and  medulla  are  chiefly  supplied  by  the  basilar  and 
vcrtebrals.  The  branches  of  these  are  terminal  arteries — that  is,  they 
do  not  anastomose  with  each  other,  or  with  other  branches  in  their 
neighborhood.  Hence,  thrombosis  or  emboli  of  such  branches,  or,  for 
instance,  of  a  part  of  the  basilar,  immediately  produces  arrest  of  func- 
tion, and,  besides,  unless  the  stoppage  is  again  removed,  produces 
anaemic  necrosis  of  the  affected  portion  of  the  pons  or  medulla. 

The  region  of  next  importance  is  that  supplied  by  the  middle 
cerebral  artery  (the  artery  of  the  fissure  of  Sylvius).  This,  as  well  as 
the  regions  of  the  cerebrum  supplied  by  each  of  the  two  other  arteries 
supplying  portions  of  the  cerebrum,  divides  distinctly  into  two  parts, 
which  do  not  anastomose  Avith  each  other,  into  an  inner  and  a  cortical 
portion.  The  inner  region,  supplied  by  the  middle  cerebral  artery 
and  its  branches,  embraces  the  internal  capsule,  with  the  exception  of 
its  posterior  section  (sensory  tract),- the  lenticular  nucleus,  the  greater 
part  of  the  caudate  nucleus,  and  a  part  of  the  optic  thalamus.  This 
internal  region  of  the  middle  cerebral  artery  (artery  of  the  fossa  of 
Sylvius)  is  sharply  distinguished  from  the  neighboring  regions  of  the 
other  arteries  of  the  brain  :  there  are  no  anastomoses ;  hence,  con- 
tinuous occlusion  of  this  vessel  at  its  root  must  inevitably  result  in 
softening  of  the  above-named  central  portion  of  the  brain.  The 
cortical  region  of  the  middle  cerebral  artery  extends  over  the  third 
frontal  convolution,  the  anterior  central  convolution  (with  the  excep- 
tion of  the  upper  portion,  which  belongs  to  the  anterior  cerebral 
artery),  the  posterior  central  convolution,  the  superior  and  inferior 
parietal  lobes,  the  whole  region  in  the  neighborhood  of  the  fissure  of 
Sylvius,  lastly,  the  second  and  third  temporal  convolutions.  This 
cortical  portion  of  the  artery  of  the  fossa  of  Sylvius  seems  to  anasto- 
mose, in  individual  instances,  with  the  neighboring  cortical  regions  in 
a  great  variety  of  ways  ;  for  this  reason,  occlusion  of  the  artery  in  only 
a  part  of  the  cases  results  in  softening  of  this  cortical  portion  of  the 
brain. 

The  optic  centre  of  the  occipital  lobe,  the  corpora  quadrigemina, 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  4(33 

and  the  posterior  portion  of  the  internal  capsule  are  supplied  bv  the 
posterior  cerebral  artery. 

The  prominence  of  the  middle  cerebral  artery  consists  not  only  in 
the  fact  that  it  supplies  the  most  important  portion  of  the  cerebrum, 
but  also  because  it  is  within  this  region  that  both  hemorrhaores  and 
emboli  most  frequently  occur.  These  two  disturbances  chiefly  aifect 
the  internal  region  of  the  artery — the  hemorrhages,  probably,  because 
the  pressure  is  highest  in  'the  branches  that  go  directly  off  from  its 
root,  or  that  here  is  felt  most  strongly  the  rapid  changes  in  the  power 
of  the  heart;  but  emboli  much  more  frequently  disturb  the  inner 
territory  than  the  cortical,  because,  as  was  mentioned  before,  there 
are  no  anastomoses  in  the  former  region,  while  in  the  cortical  there 
are.  In  the  relation  of  the  left  carotid  to  the  aorta  (going  off  at  a 
very  acute  angle)  seems  to  lie  the  explanation  as  to  why  emboli  are 
much  more  frequent  in  the  left  middle  cerebral  artery  than  in  tha 
right. 

Symptomatology  and  Methods  of  Examination.. 

examination  of  the  seat  of  disease. 

We  learn  from  the  physiological  properties  of  the  nervous  system 
that  when  affected  by  disease  there  is  little  or  nothing  to  be  seen  at 
the  seat  of  the  disease,  while  the  symptoms  are  manifest  at  other  por- 
tions of  the  body  often  quite  distant  from  it.  Besides,  the  brain  and 
spinal  cord  are  almost  entirely  removed  from  the  possibility  of  beino- 
examined,  on  account  of  their  bony  casem'ents.  Lastly,  very  often  a 
local  disease  of  the  nervous  system,  although  it  causes  pronounced 
phenomena,  is  locally  very  indistinct.  For  all  these  reasons,  the  local 
examination  of  the  nervous  system,  in  a  number  of  its  diseases,  is 
quite  subordinate.  Still,  we  place  its  consideration  first,  because  in 
a  systematic  examination  it  belongs  there,  and  because  the  expression 
of  our  opinion  cannot  at  all  affect  the  value  which  it,  nevertheless,  in 
many  respects  possesses. 

The  Skull. — The  majority  of  the  diseases  of  the  brain  and  its 
coverings  run  their  course  without  any  manifest  effect  upon  the  skull ; 
indeed,  there  is  no  disease  of  that  organ  in  which  it  may  not  more  or 
less  frequently  happen  that  alterations  in  the  skull  were  entirely 
wanting.     If  there  are  such  alterations   in    a  portion  of  the  cases, 


464  SPECIAL  DIAGNOSIS. 

they  are  secondary  in  their  nature,  dependent  upon  disease  on  the 
inner  surface ;  in  other,  more  rare  cases,  the  alterations  of  the  skull 
are  the  cause  of  the  disease  of  the  brain. 

As  methods  of  examination,  we  mention  inspection,  palpation,  and 
measuring  or  tracing  the  shape  of  the  cranium  upon  paper. 

The  Size  of  the  Cranium. — Generally  this  is  determined  by  the 
circumference  of  the  head  over  the  glabella  and  the  occipital  protu- 
berance, and  by  estimating  the  relation  between  the  brain-case  proper 
and  the  face.  This  latter  can  be  measured  simply  by  the  eye.  In 
the  newly  born  the  circumference  of  the  head  is  39  to  40  cm.  (accord- 
ing to  others  somewhat  less).  In  the  course  of  the  first  year  it 
increases  to  about  45  cm.,  and  from  then  to  the  beginning  of  the 
twelfth  year  to  50  cm. ;  in  adults  it  amounts  to  about  55  cm.  (in  women 
it  is  generally  somewhat  less  than  in  men). 

Marked  enlargement  of  the  cranium,  macrocephalus  (to  80  cm.  and 
more  in  circumference),  occurs  with  hydrocephalus,  if  the  fontanelles 
have  not  yet  closed.  Then  the  frontal  bones  particularly  project;  the 
countenance  is  proportionally  too  small,  the  eyes  are  directed  down- 
ward, the  expression  is  often  peculiarly  staring ;  the  fontanelles  are 
very  large  and  remain  open  for  a  long  time ;  the  cranial  bones  are 
thin.  Hydrocephalus  which  occurs  later,  when  the  skull  has  already 
closed,  causes  little  or  no  enlargement  of  the  head. 

Moreover,  a  somewhat  considerable  macrocephalus  is  peculiar  to 
the  rhachitic  skull,  and  is  here  dependent  upon  thickening  of  the 
bones  of  the  skull.  But  it  is  generally  somewhat  angular  (caput 
quadratum).  There  is  no  notable  recession  of  the  bones  of  the  face 
as  in  the  former;  the  bones  give  the  impression  of  being  dense,  only 
the  occipital  bone  is  sometimes  very  thin,  even  as  paper,  sometimes 
upon  pressure  crackling  like  parchment  (be  careful !).  Here,  too, 
the  fontanelles  remain  open  abnormally  long — sometimes  into  the 
third  year.  The  distinction  from  hydrocephalus  is  made  in  the  first 
place  by  an  examination  of  the  nervous  system,  which  in  this  disease 
is  almost  always  injuriously  affected  (as  respects  its  psychic,  intel- 
lectual, and  motor  functions),  while  in  rhachitis  it  is  normal;  also 
the  evidences  of  rhachitis  are  to  be  sought  at  other  points  (the  infe- 
rior maxilla,  the  thorax,  the  bones  of  the  extremities).  Moreover,  we 
may  have  a  combination  of  hydrocephalus  and  rhachitic  thickening 
of  the  cranium. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  465 

Abnormally  small  skull,  microcephalus,  is  naturally  connected  Avith. 
abnormally  small  brain,  thus  necessarily  with  idiocy  (see). 

Form  of  the  Skull.  —  Departures  from  the  typical  form.  Here 
belong  dolichocephalus,  brachycephalus,  and  other  forms  of  head  which 
are  often  met  with  without  any  pathological  condition  of  the  brain, 
but  also  in  congenital  malformation  of  the  brain,  as  in  idiots.  Asym- 
metry of  the  skull  likewise  occurs  with  this  condition,  but  also  not 
infrequently  with  persons  who  are  perfectly  healthy  and  intelligent. 
We  discover  the  asymmetry  of  the  skull  by  viewing  it  from  above  or 
by  tracing  it  upon  paper :  measuring  the  sagittal  and  the  large  trans- 
verse diameters  of  the  cranium  with  the  calipers,  and  making  an 
outline  with  a  strip  of  lead  as  was  described  upon  page  163,  in  the 
examination  of  the  form  of  the  thorax. 

Circumscribed  projections  and  depressions  have  much  greater  path- 
ological significance,  the  latter,  however,  very  frequently  not  with 
reference  to  disease  of  the  brain  but  as  signs  of  a  general  disease. 
Projections  occur  in  disease  of  the  cranial  walls  and  of  the  dura  mater ,^ 
and  these  are  chiefly  syphilitic  gummata,  carcinoma,  and  sarcoma. 
Sinking-in,  depressions,  impressions,  may  be  traumatic.  If  there  is 
defect  of  the  bony  wall  the  defect  may  feel  like  a  fontanelle.  Soft 
and  slightly  depressed  [or  depressible]  round  spots  are  sometimes 
present  in  carcinoma  of  the  cranial  vault.  Very  important,  lastly, 
are  scar-like,  round  depressions  over  which  the  scalp  is  adherent,  and 
which  often  contain  an  actual  scar :  these  occur  as  the  result  of  healed 
syphilitic  gummata  or  deep  ulcerations.  All  these  appearances,  but 
especially  the  traumatic  and  syphilitic  depressions,  are  of  the  greatest 
diagnostic  importance.  When  the  skull  is  thickly  covered  with  hair 
they  may  be  easily  overlooked,  if  we  do  not  examine  it  with  the 
greatest  care  by  feeling  all  points. 

In  making  the  examination  of  the  cranium,  it  is  of  the  greatest 
importance  that  we  should  have  a  clear  conception  of  the  location  of 
the  brain  and  its  different  parts  with  reference  to  its  bony  casement. 
We  cannot  here  go  into  particulars,  but  attention  is  called  to  Fig.  145, 
from  which  we  especially  learn  the  relation  of  the  so-called  motor 
cortical  regions  of  the  temporal  and  occipital  lobes  to  the  cranium. 

1  The  knowledge  and  significance  of  tumors  of  the  cranium  caused  by  meningocele 
and  cephalocele  are  taught  in  works  upon  surgery. 

30 


466 


SPECIAL  DIAGNOSIS. 


The  most  important  point  is  that  the  motor  cortical  region  lies  just  in 
front  of  a  vertical  line  drawn  through  the  external  orifice  of  the 
auditory  canal. 


Fig'.  145, 


Explanation  of  the  topographical  relation  between  the  surface  of  the  brain  and  the 
skull,  c,  fissure  of  Eolando;  ^Cand  VC,  posterior  and  anterior  central  convolu- 
tion; S,  S,  8,  fossa  of  Sylvius;  P,  P,  upper  and  lower  parietal  lobes;  0,  occipital 
lobe;  C 6,  cerebellum  ;  T,  temporal  lobe ;  J?'.  Frontal  lobe.    (Strumpell  from  Ecker.) 

Sensibility  of  the  Cranium  to  Pressure.  —  This  is  ascertained 
by  pressure  with  the  finger  or  by  gentle  stroke  with  the  tip  of  the 
finger  or  the  percussion  hammer.  General  sensibility  to  pressure 
occurs  in  nervousness,  especially  nervous  pain  in  the  head.  We  also 
sometimes  meet  with  circumscribed  sensibility  to  pressure  in  nervous- 
ness, also  in  hysteria ;  but  sometimes  the  latter  corresponds  with  a 
circumscribed  meningitis,  as  this  may  be  caused  chiefly  by  tumors, 
abscess  of  the  brain,  etc.  If  there  are  other  signs  of  a  disease  of  this 
character  present,  then  its  topical  diagnosis  may  be  aided  by  palpation 
and  percussion ;  by  itself  its  results  must  be  received  with  caution. 

Regarding  the  significance  of  dilatation  of  the  veins  of  the  skull, 
see  page  260. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  467 

Suppuration  of  the  ear  and  nose  (the  latter  seldom)  plays  an  im- 
portant part  as  causes  of  meningitis  and  abscess  of  the  brain. 


THE    SPINAL    COLUMN. 

Form.  The  significance  of  the  expressions  scoliosis,  kyphosis 
(lateral  and  posterior  curvature  of  the  spine)  and  kyphoscoliosis  have 
already  been  referred  to  on  page  88.  Lordosis  is  an  abnormal  cur- 
vature forward.  If  these  curvatures  are  obtuse-angled,  none  of  them 
have  a  deleterious  effect  upon  the  spinal  cord,  or  at  least  only  excep- 
tionally. Acute-angled  kyphosis  (gibbous),  as  is  usually  caused  by 
caries  of  the  vertebrae,  also  by  fracture  of  a  vertebra,  is  of  much 
greater  importance,  [causing]  compression  of  the  cord.  It  is  to  be 
remarked  that  in  order  to  recognize  slight  lateral  curvature  it  is 
desirable  to  mark  the  s^jines  of  the  vertebrse,  without  moving  the  skin, 
with  a  blue  crayon,  aid  then  to  observe  carefully  the  line  that  is  thus 
formed.  Anj  weak  less  or  paralysis  of  the  muscles  of  the  spine  on 
one  or  both  sides  may  lead  to  secondary  curvature  of  the  spine,  espe- 
cially to  scoliosis  and  lordosis ;  see  still  further  regarding  this  under 
Function  of  the  Muscles. 

Dimmished  mobility  of  the  spinal  column,  if  it  occurs  with  respect 
to  the  whole  length  in  persons  of  mature  years,  is  often  not  patho- 
logical. Complete  general  stiffness  occurs,  also,  in  arthritis  deformans. 
If  the  stiffness  is  limited  to  a  certain  portion,  while  the  rest  of  the 
vertebrae  have  free  motion,  this  is  of  pathological  significance  (almost 
always  due  to  caries,  and  here  we  sometimes  have  stiffness  without 
curvature  of  the  spine).  Forcible  bending  is  then  generally  painful. 
The  spinal  column  is  abnormally  mobile  when  there  is  weakness  or 
paralysis  of  its  extensor  or  flexor  muscles  in  young  persons.  This  is 
especially  marked  in  juvenile  muscular  atrophy,  often  in  connection 
with  habitual  curvature. 

Sensitiveness  of  the  vertebral  column  to  pressure  (especially  of  the 
spines  of  the  vertebrae)  may  have  a  great  variety  of  significance. 
There  may  be  palpable  disease,  especially  caries,  but  also  tumors  of 
the  vertebrae,  of  the  spinal  meninges,  spinal  meningitis,  or  tabes;  but 
it  may  likewise  occur  with  spinal  irritation  (particularly  in  the  neck 
and  between  the  shoulder-blades),  as  well  as  in  hysteria,  and  here  it 
may  be  excessive.     We  discover  this  sensibility  by  strong  pressure, 


468  SPECIAL  DIAGNOSIS. 

or  by  striking  the  spines  of  the  vertebrae.  Often,  but  by  no  means 
always,  there  is  at  the  same  time  painful  sensibility  when  a  hot  sponge 
or  the  cathode  of  the  galvanic  current  is  passed  over  it. 

Here,  also,  belongs  the  rigidity  of  the  neck  in  meningitis,  particu- 
larly basilar — an  important  sign  of  this  disease ;  also,  the  rigidity  of 
the  whole  spinal  column  in  spinal  meningitis.  With  the  former,  by 
the  contraction  of  the  cervical  extensors  of  the  head,  the  latter  is 
often  bent  back  to  a  marked  degree,  "  boring  into  the  pillow." 
Backward  bending  of  the  vertebral  column — opisthotonus — likewise 
occurs  with  attacks  of  tetanus ;  with  epileptic,  and  especially  hys- 
terical, convulsions.  With  the  latter,  as  the  "  arc  de  cercle,"  there 
are  sometimes  incredible  distortions. 

The  anatomical  relation  of  the  cord  to  the  spinal  column  is  as 
follows :  the  cervical  enlargement  of  the  cord  corresponds  about  with 
the  third  cervical  or  the  first  dorsal  spine,  the  lumbar  enlargement 
about  on  the  level  with  the  ninth  dorsal  to  the  first  lumbar  vertebral 
spine;  the  conus  terminalis  begins  at  the  first  or  second  lumbar 
vertebra. 

THE    PERIPHERAL   NERVES    AND   THEIR    SURROUNDINGS. 

The  nerves,  as  the  seat  of  disease,  come  into  consideration  in  all 
peripheral  paralyses  and  in  neuralgias  (also  among  others,  in  reflex 
epilepsy).  In  order  directly  to  examine  a  nerve-trunk,  an  exact 
knowledge  of  its  course  is  necessary,  and  also  of  the  organs  that 
surround  it,  from  Avhich  an  injurious  efiect  upon  the  nerve  may 
proceed. 

By  the  examination  of  a  nerve  we  learn  its  anatomical  condition : 
any  possible  symmetrical  thickening,  with  neuritis  or  perineuritis, 
unequal  thickening  or  tumors  in  the  nerve,  with  neurofibroma, 
neuroma;  also  any  possible  sensibility  to  pressure,  as  occurs  with 
neuritis  along  the  whole  length  of  the  diseased  nerve,  although  this 
may  be  entirely  absent.  Finally,  here  belong  the  sensitive  points  in 
neuralgias  (see  below). 

Moreover,  a  special  examination  must  be  made  of  certain  points, 
which,  from  any  cause  whatsoever,  may  easily  be  the  starting-point 
of  a  disease  of  a  peripheral  nerve.  These  are  :  (a)  those  points  Avhere 
a  nerve  is  especially  exposed  to  traumatism,  because  it  lies  near  the 


EXAMINATION  OF  THE  NERVOUS  SFSTEM.  469 

surface  of  the  body  (especially  if  it  at  the  same  time  lies  over  a  bone). 
These  situations  essentially  coincide,  in  part,  with  the  electro-motor 
points  to  be  mentioned  later.  Severe  injuries,  deep  punctures,  etc., 
of  course,  may  destroy  a  nerve  at  any  point.  They  are :  (5)  neigh- 
borhoods where  a  nerve  may  be  exposed  to  injury  from  other  organs. 
Here  belongs  compression  by  development  of  callus  about  the  seat 
of  fracture,  especially  of  the  bones  of  the  extremities ;  also  com- 
pression and  sometimes  inflammatory  irritation  from  glandular  tumors 
(axilla,  neck,  etc.),  aneurism,  hernia  (crural  nerve) ;  lesion  of  the 
facial  nerve  caused  by  caries  of  the  petrous  portion  [of  the  temporal 
bone],  etc.  Indeed,  in  case  of  lesion  of  a  peripheral  nerve  we  are 
frequently  able  to  find  the  seat  of  the  disease  in  this  sense ;  but  in 
every  single  case  it  must  be  looked  for. 

An  extremely  instructive  case  from  the  standpoint  of  diagnosis 
of  the  locus  morhi  was  observed  by  Erb,  Avhich  was  reported  by  the 
author.  It  was  a  case  of  ulnar  neuritis  resulting  from  exposure  of 
the  ulnar  nerve  from  the  fracture  of  the  internal  condyle  of  the 
humerus.  The  author  has  recently  seen  a  similar  case  :  both  internal 
condyles  of  the  humerus  projected;  the  sulcus  ulnaris  was  broad  and 
shallow.  In  the  first  case  there  was  a  unilateral,  in  the  second  a 
bilateral,  ulnar  neuritis  resulting  from  frequent  injury  to  the  nerve 
at  its  exposed  point. 

EXAMINATION    OF   THE    CONDITION    OF   THE    MIND. 

In  this  section,  which  touches  upon  a  territory  foreign  to  this  work, 
— the  mental  state — we  must,  of  course,  limit  ourselves  to  a  brief 
mention  of  what  is  necessary  in  making  a  medical  examination. 

Mode  of  examination.  An  attentive  observation  of  the  behavior  of 
the  patient  in  bed,  the  expression  of  his  countenance,  his  position, 
the  reaction  to  external  impressions,  give  many  disclosures  regarding 
the  faculty  of  perception,  and  of  his  sensibility  [or  well-being].  By 
engaging  the  patient  in  conversation  (taking  the  anamnesis,. page  18), 
we  are  able  to  discover  more  regarding  these  points,  and  to  judge  of 
the  intellectual  activity  :  memory,  imagination,  possible  delusions,  the 
ability  to  think  logically.  In  testing  the  memory,  we  take  notice  of 
the  recollection  of  things  that  are  long  past,  as  well  as  of  more  recent 
events,  or  of  what  has  taken  place  during  the  present  illness.     The 


470  SPECIAL  DIAGNOSIS. 

test  of  the  power  of  thought  and  of  the  imagination  is  made  by  more 
or  less  simple  arithmetical  problems  and  by  questions  which  are  suit- 
able to  the  social  position  and  the  occupation  of  the  patient.  We 
observe  the  great  difference  which  various  degrees  of  education  pro- 
duce in  patients  affected  with  the  same  disease,  and  we  also  take 
into  consideration  the  age  of  the  patient.  We  observe  any  possible 
diminution  or  increase  of  action,  both  instinctive,  as  the  taking  of 
food,  or  sexual  indulgences,  and  of  actions  with  conscious  purpose. 

This  expresses  in  general  terms  the  course  of  the  examination. 
To  be  sure,  we  shall  very  frequently  be  obliged,  in  order  to  recognize 
the  first  traces  of  a  mental  disorder,  to  take  into  consideration 
whether  the  patient  has  changed  in  his  nature  or  behavior.  Thus, 
for  example,  if  a  person  becomes  suddenly  forgetful,  careless,  and 
disorderly,  this  Avill  have  quite  a  different  significance  than  if  he 
had  always  from  his  youth  been  so.  Of  course,  in  regard  to  these 
things  we  must  chiefly  rely  upon  the  statements  of  his  relatives. 

In  what  follows  is  given  the  explanation  of  the  terms  that  have 
been  adopted  in  the  medical  clinic,  and  the  phenomena  that  accom- 
pany the  several  conditions  : 

Disturbances  of  consciousness  are  designated,  according  to  their 
severity,  as :  stupor,  also  somnolence  (sleepiness,  lethargy,  from 
which  the  patient  can  easily  be  awakensd) ;  sopor,  in  which  the 
patient  can  only  be  awakened  by  decided  appeals  to  his  senses  ;  coma^ 
or  complete  loss  of  consciousness,  in  which  the  patient  cannot  be 
awakened  in  any  way.  The  slightest  degree  of  obtunded  conscious- 
ness manifests  itself  in  the  scarcely  noticeable  trouble  which  it  costs 
the  patient  to  collect  himself  in  order  to  answer  a  question,  or  by  his 
indifference  with  respect  to  being  sick — a  subjective  sense  of  well- 
being.  Further,  there  is  an  indication  given  by  the  sensibility  to 
pain,  and  the  arbitrary  or  involuntary  voidance  of  the  stools  and 
urine.  In  this  respect,  the  sensibility  to  pain  often  does  not  coincide 
with  the  other  manifestations  of  consciousness. 

.Disturbance  of  consciousness  occurs  :  in  acute  infeciious  diseases ; 
especially  in  typhoid  fever  (see  more  below),  where  the  early  mani- 
festation of  dulness  has  diagnostic  value ;  but  it  may  accompany  any 
infectious  disease,  and  may  pass  into  deep  coma;  in  acute  poisoning 
of  various  kinds,  especially  from  narcotics;  as  ursemic,  diabetic,  carci- 
nomatous coma;  as  epileptic,  apoplectic  coma;  in  meningitis;  in  the 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  47 1 

most  varying  diseases  of  the  brain,  especially  in  tumors  of  the  brain 
and  its  meninges.  In  the  different  forms  of  meningitis,  however, 
consciousness  may  be  retained  for  a  remarkably  long  time.  In  tumors 
of  the  brain  there  is  often  for  a  long  time  a  slight  obscuration.  It 
occurs  also  in  injuries  and  concussion  of  the  cranium ;  in  large  hemor- 
rhages ;  in  all  chronic  cachexia  at  the  end  of  life,  at  any  rate  in  the 
last  moments. 

A  patient  who  is  in  deiep  coma  when  he  comes  under  the  eye  of 
the  physician  always  causes  great  difficulty  in  diagnosis,  the  greatest 
when  he  can  make  no  inquiry  in  regard  to  the  patient.  Systematic 
examination  of  the  whole  body  is  to  be  made:  of  the  cranium  for 
wounds;  of  the  heart  and  vessels;  for  evidences  of  apoplexy,  menin- 
gitis; for  signs  of  poisoning;  of  the  urine,  which  is  to  be  drawn  with 
the  catheter  (for  sugar,  reaction  for  chloride  of  iron,  for  albumin, 
casts;  for  certain  poisons  or  as  evidence  of  certain  poisons,  haemo- 
globin) ;  lastly,  of  the  stomach  by  evacuation  (poisons). 

SPECIAL  PHENOMENA  OF  OBTUNDED  CONSCIOUSNESS. 

Delirium,  that  is,  talk  and  gesticulations  arising  from  delusions. 
It  may  follow  any  disturbance  of  consciousness,  but  it  occurs  especially 
frequently  with  acute  infectious  diseases ;  with  severe  cachexia,  often  as 
the  end  of  life  approaches;  finally,  as  delirium  tremens  seu  potatorum, 
in  chronic  alcoholic  poisoning.  The  latter  manifests  itself  by  talkative- 
ness, restlessness,  rapid  alternations  between  passion  and  great  anxiety, 
fear,  hallucinations  of  sight  (small  black  animals,  especially  mice,  etc.), 
loss  of  sensibility  to  pain  and  cold ;  besides  alcoholic  trembling  (see). 

The  expression  "  muttering  delirium  "  is  used  to  designate  a  low 
murmuring  with  profound  disturbance  of  consciousness.  It  is  always 
a  serious  indication  of  great  weakness  and  occurs  particularly  with 
typlioid  fever. 

Hysterical  delirium  forms  a  transition  to  the  true  psychoses,  which 
cannot  be  treated  here. 

Spasms,  vomiting,  see  below. 

Loss  of  consciousness,  which  quickly  passes  off,  occurs  as  "  syn- 
cope," "dizziness."  This  may  be  very  benign,  as  in  ansemia  and 
chlorosis,  nervousness,  great  excitement,  or  severe  pain.  But  it 
may  have  a  serious  significance  in  elderly  people  as  precursors  of 
apoplexy,  or  as  slight  epileptic  attacks  (petit  mal) ;  lastly,  it  occurs 
in  all  possible  chronic  diseases  of  the  brain,  but  especially  in  progres- 


472  SPECIAL  DIAGNOSIS. 

sive  paralysis.  All  of  these  conditions  must  be  thought  of  when 
attacks  of  dizziness  occur  frequently  in  the  same  individual. 

Dizziness,  vertigo.  In  many  respects  this  is  to  be  looked  upon  as 
a  slight,  temporary  loss  of  consciousness,  or  connected  with  it  (see 
above).  But  it  only  indicates  a  disturbance  of  the  sense  of  equilibrium 
and  occurs  as  such  most  purely  as  a  swimming  of  the  eyes  in  diplopia 
(see  Eyes)  from  deception  regarding  the  location  of  objects  in  space 
and  regarding  the  level  of  the  floor.  It  also  occurs  in  affections  of 
the  ear  (vertigo  ab  aure  Isesa) ;  in  tumors  of  the  brain,  especially  of 
the  vermiform  process  of  the  cerebellum  ;  in  multiple  sclerosis  ;  with 
diseases  of  the  stomach  (vertigo  a  stomacho  laeso) ;  in  anaemia,  and  in 
cerebral  neurasthenia. 

Pathological  depreciation  of  the  power  of  the  mind  to  perform  its 
functions  is  designated  as  imbecility.  It  occurs  in  all  gradations 
from  moderate  diminution  in  the  perceptive  faculties,  to  a  complete 
animal  condition.  Congenital  imbecility  is  designated  idiocy.,  when 
accompanied  with  certain  physical  manifestations  as  cretinism.  As 
an  acquired  condition  it  occurs  as  dementia  senilis,  also  in  organic 
diseases  of  the  brain,  especially  tumors,  apoplexy,  multiple  sclerosis ; 
but  also,  as  a  temporary  condition  in  convalescence  from  severe  dis- 
eases, there  is  a  slight  imbecility.  Imbecility  with  delusions  of  great- 
ness is  a  tolerably  characteristic  sign  of  progressive  paralysis. 

Of  disturbances  of  volitional  impulses  are  to  be  mentioned :  abulia 
(hypochondria,  drunkenness,  indulgence  in  morphia) ;  loss  of  desire 
for  food  :  anorexia ;  certain  forms  of  pathological  excesses  :  boulimia 
(a  morbidly  great  and  unnatural  appetite  for  eating  all  sorts  of  things), 
nymphomania  and  satyriasis  (abnormal  sexual  desires). 

Disturbances  of  Sensibility. 

1.  sensitiveness  to  peripheral  irritation. 

The  determination  of  the  sensibility  which  a  patient  has  for  irrita- 
tions applied  from  the  periphery  (by  the  physician)  is  made  difficult 
by  the  fact  that  the  estimation  of  them  must  rest  with  the  patient,  who 
is  the  subject  of  the  experiment.  Subjective  sensibility,  especially  to 
pain,  without  doubt  varies  with  individuals:  with  "torpid"  persons 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  473 

and  with  the  aged  it  is  depreciated.  Moreover,  in  a  varying  degree, 
it  is  diminished  with  persons  who  are  unconscious  to  the  point  of 
entire  loss  of  sensation.  Further,  it  will  be  influenced,  when  the  irri- 
tation is  slight,  by  the  attentiveness  of  the  person  examined.  The 
report  of  what  is  discovered  in  such  examinations  depends  wholly 
upon  the  sincerity  and  good-will  of  the  patient.  We  must  always 
think  of  the  possibility  of  simulation  and  concealment,  and  the  absence 
of  favorable  intention. 

Very  little  weight  must  be  given  to  the  statements  of  the  patient 
as  to  his  capacity  to  feel.  The  most  brief  examination  is  best,  as 
securing  the  most  exact  answers,  for  we  very  often  meet  with  erroneous 
conceptions  of  the  condition  of  the  sensibility  of  the  skin. 

Whenever  we  are  testing  the  sensibility,  it  is  advisable  to  prevent 
the  patient  from  seeing  what  we  are  doing.  If  the  disease  is  uni- 
lateral, it  is  desirable  to  make  use  of  this  circumstance  to  compare  the 
diseased  with  the  healthy  side.  How  we  are  to  guard  against  decep- 
tion by  simulation,  see  below. 

Finally,  it  is  most  emphatically  recommended  that  the  individual 
should  employ  the  utmost  similarity  possible  in  the  methods  of 
making  his  examinations ;  for  only  in  this  way  is  it  possible  con- 
stantly to  sharpen  his  own  judgment.  Moreover,  every  record  of  an 
examination  should  contain  a  statement  of  how  the  result  was  ob- 
tained. 

Passing  over  the  higher  senses,  the  sensibility  to  peripheral  irrita- 
tion is  divided  into  (a)  cutaneous  sensibility,  (5)  the  so-called  deep 
sensibility. 

{a)  Cutaneous  Sensibility. 

This  again  is  divided  into  a  number  of  qualities  whose  relation  to 
each  other  and  distinction  one  from  the  other  is  not  yet  entirely  clear. 
We  avoid  any  discussion  of  disputed  points,  and  treat  the  qualities 
from  the  stand-point  of  clinical  interest. 

1.  The  sense  of  touch,  sensibility  to  contact.  We  test  this  by 
gently  touching  the  skin  with  the  tip  of  the  finger,  the  patient  keeping 
his  eyes  closed,  and  whenever  he  feels  the  touch  saying  "now"  ;  it  is 
better  if  he  will  also  say  "  on  the  hand,"  or  on  the  given  finger,  etc. 
Thus  we  approximately  test  the  sense  of  locality  (see  below).  And  it 
is  also  recommended,  in  order  to  shorten  the  examination,  to  test  the 


474  SPECIAL  DIAGNOSIS. 

Jatier  immediately  more  exactly  by  having  the  patient  designate  with 
the  tip  of  the  finger  the  spot  that  is  touched.  If  he  is  able  to  do  this 
then  his  sense  of  touch  and  of  locality  is  normal ;  if  he  cannot, 
there  may  be  several  reasons  for  his  inability,  as  disturbance  of  the 
sense  of  touch  and  of  locality,  sometimes  of  the  muscular  sense  (see 
below).  Then  we  must  endeavor  to  separate  the  sense  of  touch  from 
the  sense  of  locality. 

In  many  cases  of  slight  disturbance  the  patient  is  able  to  feel  the 
contact,  but  it  is  duller  and  different  from  what  it  is  in  normal  places. 
Then  we  often  obtain  more  exact  information  if  we  touch  him  with 
rough  and  soft  materials,  and  the  like.  In  other  cases  this  procedure 
is  unnecessary. 

2.  The  local  sense,  the  power  of  localization,  is  tested  by  having 
the  patient  tell  exactly  where  he  has  been  touched.  A  healthy  per- 
son can  tell  this  with  different  degrees  of  accuracy,  according  to  the 
portion  of  the  body  which  is  touched.  This  about  corresponds  with 
the  distances  on  the  body  which  the  related  sense  of  space  has  been 
found  to  give.     (See  below.) 

Testing  the  sense  of  space  (only  required  when  from  any  reasons 
the  sensibility  must  be  tested  with  the  greatest  exactness)  is  best  done 
with  Sieveking's  aesthesiometer :  by  means  of  two  sliding  points  we 
are  able  to  measure  the  shortest  distance  at  which  the  two  points  can 
be  recognized  as  two  separate  objects.  In  health  the  minimal  dis- 
tance, on  the  average,  is  as  follows  : 


At  the  tip  of  the  finger 
In  the  palm  of  the  hand 
On  the  back  of  the  hand 
The  forearm  and  the  leg 
The  back  . 
The  upper  arm  and  thigh 


2.5  to  5  mm. 
8  to  12     " 
31  " 

about  40  " 
40  to  70  " 
about  75  " 


Analogous,  although  in  its  results  not  wholly  corresponding  to 
those  of  the  above-mentioned  method,  is  that  of  testing  the  sensation 
of  movements  (Leube) :  it  relates  to  the  power  to  distinguish  points 
and  the  shortest  lines  that  can  be  drawn  upon  the  skin. 

3.  The  sense  of  pressure  residing  in  the  skin  is  tested  by  the  ability 
of  the  patient  to  determine  the  smallest  differences  between  weights 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  475 

placed  npon  the  skin.  The  limb  must  lie  firmly,  so  that  the  muscular 
sense  (see)  is  excluded.  It  is  best  to  take  blocks  of  wood  of  the 
same  size  (instead  of  metal),  but  made  of  different  weight  by  being 
loaded  with  lead.  The  healthy  person  perceives  differences  of  weight 
which  are  equal  to  about  -2^  to  -3^  of  the  absolute  weight  of  the  bodies 
employed.  Partial  paralysis  of  the  sense  of  pressure  is  frequently 
observed,  especially  in  tabes. 

4.  The  sense  of  warmth  and  cold.  This  is  most  quickly  and 
simply  tested  by  breathing  and  blowing  upon  the  skin.  Healthy 
persons  distinguish  the  first  from  the  second  perfectly  well.  This 
method,  however,  is  entirely  unsatisfactory,  because  the  finer  disturb- 
ances of  the  sense  of  cold  and  heat  are  not  revealed  by  it.  Somewhat 
more  exact  is  the  test  made  by  means  of  two  test-tubes  filled  with 
water  at  different  temperatures.  We  must  select  a  difference  of  tem- 
perature which  we  ourselves  distinctly  recognize,  as,  for  instance,  by 
passing  the  hand  over  them.  If,  with  one  of  these  methods,  we  find 
a  disturbance  of  one  of  the  two  temperature-senses,  then  we  can  more 
exactly  determine  the  degree  of  this  disturbance  by  employing  tem- 
peratures which  vary  still  more ;  hence,  very  low  or  very  high  (ice, 
hot  water).  At  the  same  time  we  can  thus  determine  the  temperature 
at  which  cold-  or  heat-pain  begins. 

A  finer  test  of  the  sense  of  heat  is  made  by  the  aid  of  the  thermses- 
thesiometer  We  recommend  Nothnagel's — two  cylindrical  wooden 
vessels,  with  metal  bottoms,  into  each  of  which  is  dipped  a  thermom- 
eter to  test  the  temperature  of  the  water  that  is  poured  into  them. 
In  a  very  imperfect  way  we  may  make  a  substitute  for  this  thermaes- 
thesiometer  by  using  two  reagent  glasses  half  filled  with  water.  In 
these  are  placed  thermometers  surrounded  by  pledgets  of  wadding. 
The  temperature  of  the  glasses  is  varied  by  dipping  them  into  vessels 
of  cold  or  hot  water.  The  thermgesthesiometer  enables  us  to  deter- 
mine exactly  the  fineness  of  the  sensibility  to  heat  and  cold.  The 
normal  fineness  of  the  sensibility  to  heat  differs  with  the  absolute 
height  of  the  temperature  which  we  select.  The  temperatures  between 
27°  C.  and  33°  C.  are  most  delicately  distinguished.  Here  the 
recognizable  differences  in  health  average  0  5°  C,  except  over  the 
legs,  where  the  number  may  be  somewhat  larger,  and  on  the  back, 
where  it  is  about  1°  0.      On  the  cheeks  it  is  about  0.25°  C. 


476 


SPECIAL  DIAGNOSIS. 


Fig.  146. 


5.  Sensihility  to  pain}  We  recommend  to  test  exclusively  by 
pinching  a  fold  of  skin  between  two  fingers,  because  in  this  way,  with 

some  practice — it  depends  very  much 
upon  the  size  of  the  fold  of  skin  that  is 
taken,  and  it  is  recommended  always  to 
press  the  rounded  portion  of  the  skin 
— we  can  best  attain  some  uniformity 
in  regard  to  the  amount  of  irritation 
employed  each  time.  (Regarding  pain 
caused  by  faradization,  see  below.) 
With  patients  who  are  unconscious  it 
very  often  happens  that  the  sensibility 
to  pain  is  the  only  quality  of  sensation 
that  is  accessible  to  examination. 
When  there  is  very  decided  uncon- 
sciousness we  are  made  aware  of  it  by 
the  possible  distortion  of  the  counte- 
nance on  account  of  pain  or  even  a 
withdrawing  of  an  extremity  (not  to  be 
confounded  with  reflex  of  the  skin,  see 
below). 

6.  Electric  sensibility.  By  the  galvanic  as  Avell  as  the  faradic 
current  we  can  develop  an  obj ectively- visible  as  Avell  as  subjectively- 
painful  sensibility  of  the  skin.  We  confine  ourselves  to  the  descrip- 
tion of  the  farado- cutaneous  sensibility. 

It  is  best  obtained  by  employing  Erb's  electrode  for  testing  farado- 
cutaneous  sensibility  (made  by  St5hrer,  in  Leipzig),  which  is  a  cable 
of  insulated  copper  wires  cut  at  right  angles  with  its  axis.  We  mount 
this  electrode  upon  the  cathode  of  the  opening  current  of  a  Dubois's 
induction-coil  (the  other  electrode  may  stand  anywhere  upon  the 
body),  and  notice  the  distance  of  rotation  when  the  point  of  the  skin 
under  examination  becomes  sensitive  (minimum  of  sensation),  and 
also  where  it  stands  Avhen  pain  is  produced.  Then,  besides,  we  are 
to  test  the  galvanic  resistance  at  each  point  tested  (see  under  Elec- 
trical Examination  for  Motility),  in  order  to  have  an  approximate 
guide  as  to  how  sti'ong  a  current,  furnished  by  Dubois's  apparatus,  is 


Erb's  electrode  fortesting  the  sen- 
sibility of  the  skin,  a,  tube  of  hard 
rubber;  b,  free  surface  of  the  elec- 
trode.    (Erb.) 


^  Corresponding  with  the  mode  of  procedure  in  making   an  examination,  this  is 
included  here,  although  it  properly  belongs  with  common  sensation  (which  see). 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  477 

exhausted  by  the  resistance  of  the  body  (or  of  the  skin)  at  the  indi- 
vidual points  ;  hence,  how  much  of  it  is  used  up  each  time  in  produc- 
ing the  irritation  of  the  skin.  The  following  table  gives  the  average 
figures  of  health  as  found  by  Erb,  but  we  remark  that  the  figures 
change  according  to  the  strength  and  construction  of  the  induction 
apparatus  employed,  and  also  that  the  deviation  of  the  needle  (for 
testing  the  galvanic  resistance)  was  attached  to  an  old  galvanometer 
without  absolute  divisions.  For  both  of  these  reasons  the  relation  of 
the  figures  from  each  other,  rather  than  the  absolute  variation  of  the 
needle  indicated  by  them,  is  of  value  : 


Points  of  resistance. 

Cheeks  . 

Minimum. 

200-220 

Pain. 
130 

Deviation  of  the  needle 
with  8  elements  ;  con- 
duction resistance  150. 

26° 

Neck 

180-200 

120 

22° 

Upper  arm     . 
Forearm 

200 
190 

120 

115 

21° 

18° 

Back  of  the  hand  . 

175 

110 

15° 

Tip  of  the  finger    . 

125 

90 

2° 

Abdomen 

190 

120 

20° 

Thigh     . 

180 

115 

21° 

Lower  leg 

Back  of  the  foot     . 

170 
175 

110 
110 

19° 
10° 

Sole  of  the  foot 

110 

80 

5° 

The  method  is  further  liable  to  error,  regarding  which  we  cannot 
speak  here. 

Farado-cutaneous  sensibility  does  not  go  entirely  parallel  with  any 
other  quality  of  sensibility.  Most  frequently,  but  not  always,  the 
sensations  of  pain  produced  by  pinching,  and  the  minimal  sensations 
of  pain  produced  by  the  faradic  current,  correspond  with  each  other 
(this  is  especially  the  case  in  tabes).  The  method  has  not  yet  been 
sufficiently  studied  to  be  of  independent  diagnostic  significance,  and 
particularly  to  have  a  value  for  special  diagnosis.  Its  application  is 
chiefly  to  be  recommended  in  unilateral  slight  disturbance  of  sensi- 
bility, from  the  possibility  of  making  a  comparison  with  the  sound 
side,  which  cannot  be  quite  certainly  established  when  there  is  normal 
irritability  of  the  skin.     (Regarding  stereognosis,  see  p.  481.) 

Now,  if  by  testing  the  sensibility  we  find  it  diminished,  we  speak 
of  hypcesthesia,  often  incorrectly  spoken  of  as  anoesthesia.  If  none 
is  found — that  is,  if  the  strong  or  maximal  irritation  employed,  which 


478  SPECIAL  DIAGNOSIS. 

is  always  to  be  stated  as  accurately  as  possible,  meets  with  no  response 
— then  we  speak  of  loss  of  sensibility,  or  anaesthesia.  Heightened 
sensibility  is  hypercesthesia,  or  sensibility  to  variations  of  temperature 
and  to  pain.  In  many  cases,  especially  in  diseases  of  the  peripheral 
nerves,  the  sensibility  is  equally  altered  in  all  its  qualities  ;  in  others, 
and  especially  in  diseases  of  the  spinal  cord,  in  cerebral  anaesthesia, 
and  not  infrequently  in  hysteria,  there  exists  a  partial  paralysis  of 
sensibility.  Of  this,  the  most  frequent  form  is  the  diminution  or 
absence  of  sensibility  to  pain — analgesia. 

When  sensibility  is  slowly  conducted  {^'■delayed  sensibility  "),  it  is 
recognized  by  requiring  the  patient,  with  his  eyes  closed,  to  call  out 
"  now  "  the  instant  he  has  a  sensation.  Sometimes,  the  pause  can  be 
measured  by  seconds  (ten  seconds,  and  more).  This  phenomenon  is 
most  frequently  observed  with  reference  to  pain,  as  in  tabes  and  in 
peripheral  paralysis.  If  we  take  hold  of  the  skin,  to  pinch  it.  the 
patient  will  often  call  out  "now"  twice,  because  he  felt  the  touch, 
and  then,  later,  the  pinch:  there  is  double  sensibility.  For  this 
reason,  it  is  best  to  take  up  the  skin  first,  without  pressing  it,  and 
then  suddenly  to  pinch  it. 

Gradual  increase  of  the  sensibility  to  pain,  when  inflicted,  so  that 
just  at  the  moment  of  being  pinched  it  is  inconsiderable,  and,  later, 
the  pain  increases  markedly,  appears  by  its  phenomena  and  occurrence 
to  be  related  to  delayed  communication  of  the  pain. 

Perverse  sensibility  to  changes  of  temperature  (Striimpell)  consists 
in  cold  being  experienced  as  heat.  According  to  our  recent  views  of 
the  complete  opposition  of  the  sensibility  to  heat  and  the  sensibility 
to  cold,  this  disturbance  is  not,  as  yet,  explicable.  Yet  it  has  an 
analogy  in  those  rare  anomalies  of  sensibility  where  a  gentle  touch  is 
felt  as  cold. 

After- sensibility  (Naunyn)  is  a  term  used  to  describe  a  pain  that, 
when  first  inflicted,  immediately  subsides,  but  for  some  time  after 
returns,  and,  indeed,  with  increase  of  intensity. 

Pulycestliesia  (Fischer) :  when  one  point  of  the  sesthesiometer  is 
placed  upon  the  surface,  it  feels  as  if  there  were  two. 

AllocMria  (Obersteiner) :  when  the  right  extremity  is  touched,  it 
is  referred  to  the  left,  and  vice  versa,  as  in  tabes,  myelitis,  hysteria, 
multiple  sclerosis. 

Local  manifestations   of  disturbed   sensibility.     Of  course,  these 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  479 

are  to  be  determined  as  accurately  as  possible.  This  is  very  easily 
done  when  the  disturbance  of  sensibility  is  sharply  bounded ;  how- 
ever, not  infrequently  the  region  of  disturbed  sensibility  of  the  skin 
passes  very  gradually  and  indistinctly  into  the  normal  portion.  Total 
anaesthesia  is  a  curiosity.  Unilateral  anaesthesia,  or  hemiancesthesia, 
not  passing  beyond  the  middle  line  of  the  body,  sometimes  affecting 
the  head,  trunk,  and  extremities  (including  the  raucous  membrane), 
in  a  similar  way,  occurs  with  certain  deposits  in  the  internal  capsule 
(in  the  posterior  third  of  its  posterior  limb),  and  in  hysteria.  In  the 
latter,  and  (it  is  said)  also  in  the  first  case,  there  is  simultaneously 
exact  unilateral  disturbance  of  all  the  higher  senses.  Para-ancesthesia 
is  anaesthesia  of  both  lower  or  both  upper  limbs.  A  zone  of  dis- 
turbed sensibility,  a  territory  of  any  extent,  may  exist  in  all  imagin- 
able parts  of  the  body.  If  it  is  small,  it  may  easily  be  overlooked, 
unless  the  search  for  it  is  very  carefully  made;  this  is  particularly 
apt  to  be  the  case  in  the  extremities.  Here,  especially  (but  also  on 
the  trunk),  we  must  carefully  determine  whether  the  anaesthesia  cor- 
responds with  the  region  of  distribution  of  a  cutaneous  nerve,  or  of  a 
mixed  nerve-trunk  (see  p.  484),  or  whether  it  is  not  confined  to  such 
a  territory — that  is,  "  diffuse  "  or  "  washed  out."  In  the  first  case  it 
"would  indicate  an  isolated  disease  of  that  particular  nerve.  Anaes- 
thesia (analgesia)  affecting  an  extremity  which  is  limited  to  the  por- 
tion distributed  about  a  joint  (say,  as  far  as  the  wrist,  or  up  as  far  as 
the  elbow-joint,  etc.),  has  been  met  with  in  certain  functional  neuroses, 
especially  of  the  so-called  hystero-traumatic  neuroses  of  the  French. 

It  may  happen — indeed,  it  very  frequently  does — that  an  anaesthetic 
territory  does  not  really  comprise  the  limits  of  a  nerve  of  the  ex- 
tremities, but  the  inner  half  of  it  is  wanting.  Thus,  in  a  radial 
paralysis,  there  may  be  an  anaesthetic  zone  (easily  overlooked)  con-, 
fined  to  a  small  part  of  the  dorsal  side  of  the  forearm.  This  results, 
either  because  the  nerve  is  not  interrupted  throughout  its  whole  trans- 
verse section,  or  because  we  have  that^  very  puzzling  phenomenon, 
the  "vicarious"  participation  of  a  neighboring  nerve. 

{b)  Deep  Sensibility. 

This  is  divided  into  the  less  important  categories  of  the  dynamic 
sense,  the    sensation  of  spasm  of  the    muscles,  and    the   important 


480  SPECIAL  DIAGNOSIS. 

so-called  muscular  sense,  which   is   a   generic  name  for  a  series  of 
sensations. 

Dynamic  sense  is  the  capacity  to  recognize  the  weight  or  the 
difference  of  weight  between  different  bodies  which  one  lifts.  It  may- 
be exactly  tested  only  with  the  upper  extremities,  and  even  here  it  is 
not  wholly  separable  from  the  pressure-sense  of  the  skin.  Different 
weights  are  placed  in  a  cloth-sling  pulled  over  the  hand  on  to  the 
wrist.     A  healthy  person  will  recognize  differences  of  one-tenth. 

Sensation  of  spasm  is  the  unpleasant  sensation  or  pain  which  is 
experienced  in  very  strong  contraction  of  the  muscles,  as  in  cramp  in 
the  calf  of  the  leg,  or  strong  faradic  muscular  stimulus  with  anaesthesia 
of  the  skin. 

Muscular  sense.  By  this  we  understand  the  ability  to  recognize, 
with  the  eyes  closed,  the  position  a  limb  is  in  (conception  of  location), 
and  the  active  and  passive  motions  of  a  limb.  It  is  due  to  the  sensi- 
bility of  the  muscles,  joints,  and  their  ligaments,  by  the  feeling  of 
varying  tension  of  the  skin  in  flexion  and  extension  of  a  joint,  by  the 
impressions  of  touch  which  come  from  portions  of  skin  being  in  con- 
tact, as  in  the  axilla  and  elsewhere.  We  test  the  sensation  of  location 
and  of  motion  in  the  arm  (with  the  eyes  closed),  in  persons  with  uni- 
lateral disease  very  simply :  we  place  the  diseased  arm  in  different 
positions,  and  have  the  patient  with  the  sound  hand  take  hold  of  the 
wrist  of  the  diseased  arm.  The  same  method  may  be  employed  in 
unilateral  disease  of  the  leg.  Besides,  it  is  well,  when  there  is  disease 
of  the  legs  and  bilateral  affection  of  the  arms,  to  have  the  patient 
describe  the  positions  in  which  they  are  placed  or  the  passive  motions 
of  the  joint  that  are  made.  We  can  also  have  the  patient  describe  and 
represent  numbers  in  the  air  with  his  hands. 

Romberg's  symptom.  The  patient  places  his  feet  close  together, 
and  as  soon  as  he  closes  his  eyes  he  begins  to  reel,  sometimes  he  may 
fall  down.  The  phenomenon  is  dependent  upon  anaesthesia  of  the 
soles  of  the  feet  and  disturbance  of  the  muscular  sense  of  the  legs, 
which  is  no  doubt  increased  by  the  existing  ataxia  (which  see),  because 
in  this  condition  the  motions  to  correct  the  swinging  are  too  violent ; 
this  is  especially  characteristic  of  tabes  dorsalis.  [But  something  of 
this  symptom  may  be  present  in  health,  owing  to  the  lack  of  vision  to 
correct  incipient  lateral  movements.  This  may  be  made  clear  by 
closing  the  eyes  and  then  attempting  to  stand  on  one  foot.] 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  481 

A  finer  test  of  the  muscular  sense  may  be  made  by  placing  before 
the  patient  a  table  with  numbered  squares  like  a  chess-board,  each 
square  measuring  about  10  cm.  on  a  side,  and  having  him  point  them 
out  with  the  eyes  open  until  he  has  them  all  in  his  head,  and  then 
with  closed  eyes  to  touch  them  with  the  hand ;  or,  on  the  other  hand, 
the  patient  moves  his  hand  about  the  squares  and  names  the  fields  as 
he  comes  to  them.  With  the  legs,  the  same  test  may  be  made  with 
cubes  measuring  10  cm.  on  a  side,  placed  one  on  top  of  another  and 
then  side  by  side.  This  test,  however,  requires  a  certain  degree  of 
intelligence  on  the  part  of  the  patient. 

Oonception  of  space  ("finding  one's  position  in  space")  can  be 
tested  by  placing  substances  of  different  thicknesses  between  his  thumb 
and  forefinger  to  ascertain  the  smallest  perceptible  differences  of 
thickness. 

In  testing  the  conceptions  of  active  motions,  we  see  that  it  is  very 
much  disturbed  in  paralysis,  ataxia,  and  chorea ;  regarding  these,  see 
below. 

The  Knowledge  of  Form  (Stereognosis). 

We  recognize  the  form  of  bodies  partly  by  the  sensibility  of  the 
skin  and  partly  by  deep  sensibility.  The  former  is  employed  more 
for  very  small  bodies  (which  we  are  able  to  grasp  with  the  hand ; 
here,  indeed,  the  hand  is  the  chief  means),  the  latter  more  for  large 
substances.  Thus  far  only  the  recognition  of  small  bodies  has  been 
sought,  especially  in  an  exact  way  by  Hofimann. 

To  make  this  test  he  selected  a  ball,  half-ball,  segment  of  a  ball,  a 
cone,  a  three-cornered  pyramid,  a  regular  octahedron,  and  a  dodec- 
ahedron— all  of  a  size  for  the  hand  to  grasp.  He  chiefly  tested  the 
hand  of  persons  in  health  and  sick  people  as  regards  their  ability  to 
recognize  these  bodies  (to  which  popular  names  were  given). 

Hoffmann  and  others  have  found  that  the  recognition  of  small 
bodies  was  principally  made  by  the  skin  and  sense  of  space  and  of 
pressure  of  the  skin,  and  to  a  less  degree  by  the  sense  of  motion  in 
the  joints  and  the  power  of  determining  the  location  in  space.  Also, 
that  the  active  to-and-fro  motion  of  the  body  in  the  hand,  for  a  dif- 
ferent reason,  comes  into  consideration :  if  the  active  motion  is  want- 
ing, then  the  stereognosis  is  hindered,  but  not  abolished. 

Formerly  the  examination  of  stereognosis  did  not  have  an  inde- 

31 


482  SPECIAL  DIAGNOSIS. 

pendent  value ;  testing  the  separate  qualities  of  sensation  is  superior 
to  it.  According  to  our  experience,  the  most  important  result  of 
Hoffmann's  examination  is  the  knowledge  that  the  separate  factors  of 
stereognosis  may  very  perfectly  act  one  for  another  when  there  are 
pathological  disturbances. 

2.    SENSIBLE    PHENOMENA    OF    IRRITATION  AND  PAIN  FROM  PRESSUEE 

UPON   NERVES. 

1.  JParcesthesia. 

This  occurs  as  a  subjective  sensation  of  touch,  like  fur,  creeping 
of  ants,  creeping  of  insects,  falling  asleep;  also  as  a  subjective  sensa- 
tion of  pain,  as  a  fine  stinging  or  pricking,  and  also  a  severe  pain ; 
lastly,  as  a  subjective  sensation  of  cold  and  heat  or  painful  burning. 

The  so-called  feeling  of  constriction,  which  occurs  most  frequently 
upon  the  trunk  in  the  region  of  the  thoracic  vertebra,  especially  in 
tabes,  but  also  in  local  disease  of  the  spinal  cord  and  its  meninges, 
belongs  here.  Generally  it  is  a  sensation  of  tension,  but  it  also  occurs 
in  all  stages  of  transition  to  genuine  neuralgic  pains,  when  it  is  deeply 
located  (see  Neuralgia). 

2.  S-pontaneous  Pain. 

Headache  (cephalalgia).  This,  according  to  the  manner  of  its 
occurrence  as  well  as  its  significance,  may  be  extremely  varied  in  its 
character.     Its  chief  forms  are  : 

(a)  Headache  produced  by  palpable  disease  of  the  meninges  in  the 
different  forms  of  meningitis;  in  all  those  diseases  of  the  cranium  and 
the  brain  which  accompany  meningitis.  If  the  affection  is  circum- 
scribed, the  headache  may  likewise  be  so,  and  it  then  sometimes 
indicates  the  location  of  the  disease;  but,  also,  often  enough  in  this 
case  it  is  not  located. 

Related  with  this  are  the  nocturnal  headaches  of  syphilis. 

(h)  The  headache  of  neurasthenia  is  quite  various  in  its  onset. 
Sometimes  it  appears  as  a  painful  pressure  in  the  head,  sometimes  as 
extremely  severe  pain ;  again  it  is  diffuse,  then  localized,  especially  at 
the  crown  of  the  head.  There  is  the  hysterical  headache,  not  infre- 
quently circumscribed  at  the  crown  (clavus  hystericus). 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  483 

(<?)  Migraine.  This  is  generally  an  unilateral  headache  occurring 
■with  pauses  of  extremely  varied  duration,  with  disturbances  of  the 
stomach,  scintillations  (see  the  eye),  tinnitus  aurium,  dilatation  or 
contraction  of  the  pupil  of  the  affected  side,  accompanied  with  other 
pains.  The  condition  is  idiopathic  or  symptomatic,  especially  in  tabes, 
tumors  of  the  brain,  also  sometimes  in  diseases  of  the  nose,  etc. 

{d)  Neuralgia  in  the  head,  see  below. 

(e)  Toxic  headache  occurs  particularly  in  chronic  poisoning  with 
lead,  mercury,  alcohol,  nicotine.  Here,  also,  belongs  the  headache  of 
ur?emia. 

(/)  There  is  a  headache  which  occurs  in  the  beginning  and  during 
the  course  of  acute  infectious  diseases,  especially  intense  and  long 
continued  in  typhoid  fever. 

{g)  Ansemic  headache ;  headache  with  gastric  dyspepsia ;  abdominal 
diseases  of  all  kinds,  especially  diseases  of  the  female  sexual  organs. 

(Ji)  The  so-called  habitual  headache.  Often  there  is  an  hereditary 
disposition  to  headache,  which  occurs  with  exertion,  excitement,  bodily 
disturbance,  as  catching  cold,  etc.,  and  the  disposition  generally  lasts 
during  the  greater  part  of  one's  life. 

Pain  in  the  spine  may  concern  the  vertebrae,  as  in  chronic  rheuma- 
tism, arthritis  deformans,  caries ;  the  spinal  muscles,  as  in  muscular 
rheumatism  ;  the  spinal  cord  or  its  meninges,  especially  in  meningitis 
and  in  tabes  with  tumors.  But  it  occurs  very  frequently,  and  is 
especially  torturing,  in  neurasthenia  and  spinal  irritation.  (See,  also, 
■what  was  previously  said  regarding  the  vertebrae.) 

Neuralgia.  This  is  generally  a  severe  paroxysmal  pain  occurring 
in  the  region  of  one  or  more  distinct  nerves.  It  may  be  idiopathic 
or  result  from  catching  cold,  but  it  may  also  be  symptomatic,  with 
the  greatest  variety  of  significance.  The  principal  varieties  of  neu- 
ralgia are  those  produced  by  mechanical  irritation  (pressure  of  a 
tumor,  aneurism,  periostitis,  etc.) ;  sequela  of  inflammation  of  the 
aifected  nerve ;  neuralgia  dependent  upon  infectious  or  toxic  influences  ^ 
(malaria,  syphilis,  lead,  mercury,  nicotine,  etc.);  or  accompanying 
constitutional  diseases,  as  diabetes,  gout,  phthisis.  In  every  neuralgia, 
we  are  to  keep  in  mind  the  whole  course  of  the  affected  nerve,  and 
consider  where  and  how  it  may  be  injured,  and  how  such  a  local 
injury  may  directly  or  indirectly  be  discovered. 

Of  special    importance  are    the    neuralgic,  lightning,  lancinating 


484  SPECIAL  DIAGNOSIS. 

pains,  in  the  initial  stage  of  tabes  dorsalis.  They  occur  very  much 
more  frequently  in  the  lower  extremities  and  the  trunk  in  the  region 
of  the  intercostal  nerves,  and  nowadays  are  not  infrequently  con- 
founded with  rheumatism.  Also  in  the  beginning  of  multiple  neuritis 
there  are  neuralgic  pains,  although  generally  of  moderate  intensity. 

We  have  previously  mentioned  the  pain  produced  by  pressure  upon 
the  head  and  upon  the  vertebrae.  The  peripheral  nerve  are  sensitive 
to  pressure  in  neuritis  whenever  this  is  accompanied  by  actual  inflam- 
matory phenomena  in  the  nerve,  or  there  is  perineuritis.  Very  fre- 
quently there  is  especially  pronounced  tenderness  of  the  nerve  during 
an  attack  of  neuralgia,  but  also  often,  although  to  a  slighter  degree, 
in  the  intervals.  This  tenderness  is  very  great  at  certain  points  of 
the  nerves,  especially  where  the  nerve  can  be  pressed  against  the  bone 
(Valleix's  points)  [points  douloureux]. 

Tenderness  and  spontaneous  pain  in  the  joints,  without  anatomical 
changes,  and  generally  very  changeable  in  severity,  are  characteristic 
of  articular  neuralgia. 


3.    DISTRIBUTION   OF   THE  'SENSORY   CUTANEOUS    NERVES. 

It  is  recommended  that  the  accompanying  figures  [Figs.  147  and 
148]  be  studied,  in  connection  with  which  we  will  draw  attention  to 
a  few  points  which  seem  to  us  to  be  especially  important. 

1.  The  nerves  of  the  head.  It  is  to  be  noticed  that  the  nerve  F^ 
also  supplies  the  conjunctiva  and  a  portion  of  the  mucous  membrane 
of  the  nose;  further,  that  when  it  is  paralyzed,  we  observe  severe 
inflammation  and  ulceration  of  the  eye  (ophthalmia  neuroparalytica), 
which,  until  recently,  were  regarded  by  most  persons  as  arising  from 
lesions,  as  by  dust,  etc.,  which  were  not  warded  off  because  they  had 
not  been  seen.  The  author  inclines  to  the  old  view  that  the  disturb- 
ance of  nutrition  forms  the  starting-point  of  the  trouble.  Nerve  F'g 
supplies  the  mucous  membrane  of  the  superior  maxilla,  a  part  of  the 
gums  and  of  the  nose,  the  upper  teeth,  and  the  chorda  [tympani]  ; 
hence  sometimes  there  is  disturbance  of  the  taste  at  the  anterior  por- 
tion [two-thirds]  of  the  tongue.  Nerve  V^  supplies  a  portion  of  the 
tongue  and  the  mucous  membrane  of  the  cheek,  and  presides  over  the 
secretion  of  saliva.     It  contains  motor  fibres,  of  which  the  most  im- 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 


485 


portant  are  those  distributed  to  the  muscles  of  mastication  (masseter, 
temporalis,  pterygoideus  ext.  et  int.) 

2.  Nerves  of  the  neck  and  trunk.  These  do  not  require  any  fur- 
ther explanation. 

3.  Nerves  of  the  shoulder,  arm,  and  hand.  Here  we  are  especially 
to  note  the  smallness  of  the  cutaneous  filaments  of  the  radial  nerve 
that  supply  the  dorsal  side  of  the  forearm.     Anaesthesia  here  may 


Fig.  147. 


Fig.  148. 


Figs.  147  and  148.  Distribution  of  the  cutaneous  sensitive  nerves  upon  the  head 
(Seeligmueller).  oma,  omi,  N.  occipit.  niaj.  and  minor  (from  the  IST.  ceiTrical,  II.  and 
III.);  am,  'N.  auricular,  magn.  (from  IST.  cervic.  III.);  cs,  N.  cervical,  superfic.  (from  IT. 
eervic.  III.) ;  V-^,  first  branch  of  the  fifth  {so,  N.  supraorbit. ;  st  N.,  supratrochl. ;  it,  2T. 
infratrochl. ;  e,  IN",  ethmoid;  I,  'N.  lachrymal);  T2,  second  branch  of  the  fifth  {sm,  IT. 
subcutan.  malae  sen  zygomaticus) ;  T3,  third  branch  of  fifth  (ai,  N.  auriculo-tempor.; 
b,  N.  buccinator. ;  m,  N.  mental  j ;  3,  posterior  branches  of  the  cervical  nerves. 


easily  he  overlooked.  It  is  to  he  remarked,  also,  that  the  distribution 
of  the  cutaneous  nerves  to  the  fingers,  and  also  to  the  hand,  is  sub- 
ject to  some  changes,  so  that  slight  variations  from  the  arrangement 
usually  described  ought  not  to  lead  to  mistake.  Lastly,  very  often 
on  examination  of  a  peripheral  paralysis  it  is  found  that  the  extension 
of  the  sensory  disturbance  lags  behind  that  of  the  motor.  The 
phenomenon  is  largely  explained  by  a  vicarious  participation  of  neigh- 
boring cutaneous  nerves  in  a  portion  of  the  territory  affected  (not- 


486 


SPECIAL  DIAGNOSIS. 

Fis.  149. 


Distribution  of  the  cutaneous  nerves  to  the  shoulder,  arm,  and  hand  (Henle).  The 
region  of  the  N.  radial  is  represented  by  the  unbroken  hatched  line,  that  of  the  N. 
ulnaris  by  the  broken  hatched  lines,  a,  anterior,  h,  posterior  surface ;  sc,  Nn.  supra- 
scapular (plexus  cervicalis);  ax,  chief  branch  of  N.  axillar;  cps,  cpi,  Nn.  cutanei  post, 
sup.  and  inf.  (from  IST.  radialis) ;  ra,  terminal  branches  of  N.  radial ;  cm,  cl,  Nn.  cutanei 
medius  (also  to  the  plexus)  and  lateralis  (chiefly  to  the  IST.  medianus)  ;  cp,  N.  cutan. 
palmar.,  K.  rad.;  cmd,  N.  cutan.  medialis;  me,  F.  medianus;  u,  N.  ulnaris;  epu,  N. 
cutan.  palm,  ulnaris. 

withstanding  the  many  investigations  regarding  its  existence,  this 
idea  of  vicarious  action  has  not  yet  been  as  clearly  explained  as  is 
desirable). 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 

Fig.  150. 


487 


Distribution  of  the  cutaneous  nerves  of  the  lower  extremity.  (Henle.)  ii,  'N.  ileo- 
inguinal  (plex.  lumb.j;  li,  N.  lumbo-inguinal  (to  the  genito-crural.  plex.  lumbal.);  se, 
N.  spermat. ext.  (to  the  genito-crural.) ;  cp,  E".  cutan.  post.  (plex.  ischiad.) ;  cl,  N".  cutan. 
lateral,  (plex.  lumb.);  cr,  N.  cruralis  (plex.  lumbal.);  obt,  IT.  obturator,  (plex.  lumb.); 
sa,  N.  saphen.  (plex.  lumbal.);  cpe,  N.  commuui  peron.  (IST.  peron.  tibial.);  cti,  N". 
commun.  tibial.;  per' ,  per" ,  1^  peronsei  ram.  superfie.  et  prof.;  cpvi,  K.  cutan.  post, 
med.  fplex  ischiad.);  cpp,  N.  cut.  plant,  propr.  fN.  tib.);  plm, pll,  F.  plantar,  medial, 
et  lateral.  (N.  tib.). 

Paralysis  of  the  brachial  plexus  at  Erb's  point  (see  Electrical  Ex- 
amination) sometimes  causes  anaesthesia  in  the  region  of  the  median 
nerve.     Paralysis  from  compression  of  the  radial  [musculo-spiral]  at 


488  SPECIAL  DIAGNOSIS. 

the  point  where  it  passes  around  [the  humerus]  causes  sensory  disturb- 
ance only  at  the  hand  (see  Electrical  Examination),  because  the  pos- 
terior cutaneous  nerves  [internal,  supplying  the  posterior  and  internal 
aspects  of  the  arm  as  far  as  the  elbow ;  and  external,  arising  from  the 
nerve  on  the  outer  border  of  the  arm,  is  distributed  to  the  back  of  the 
forearm]  are  given  off  above  the  point  of  circumflexion.  On  the  other 
hand,  compression  of  the  radial  in  the  axilla  (crutch-paralysis)  often 
causes  anaesthesia  of  the  forearm. 

4.  Nerves  of  the  lower  extremities.  (See  the  accompanying 
figure— Fig.  150.) 

Disturbances  of  Motility. 

In  this  connection  we  consider  not  alone  the  disturbances  of  mus- 
cular action  in  the  strict  sense,  but  also  the  manifestations  as  respects 
tonus  and  the  nutrition  of  the  muscles,  the  co5rdination  of  their 
actions,  their  electrical  and  mechanical  irritability,  and  their  reflex 
manifestations. 

1,    PARALYSIS. 

By  paralysis  of  a  voluntary  muscle,  we  understand  a  condition  in 
which,  by  the  action  of -the  will,  it  can  only  to  a  diminished  extent, 
or  cannot  at  all,  be  made  to  contract.  If  there  is  complete  absence  of 
voluntary  contraction,  we  call  the  condition  paralysis ;  if  the  power 
of  voluntary  contraction  is  only  diminished,  it  is  called  paresis. 
Paralysis  is  the  result  of  some  anomaly  of  the  muscular  nervous 
system  or  of  its  motor  terminal  apparatus. 

The  loss  of  motion  due  to  stiffness  of  the  joint  has  nothing  to  do 
with  paralysis.  Such  inability  to  move  a  joint  is  especially  frequent 
in  the  extremities,  and  may  lead  the  inexperienced  into  error.  If 
there  is  simultaneous  stiffness  of  the  joint  and  paralysis,  it  may  be 
extremely  difficult  to  determine  the  existence  of  the  latter.  Diminu- 
tion of  power  of  motion  caused  by  pain  has  nothing  to  do  with  paralysis 
when  there  is  only  a  want  of  self-control  on  the  part  of  the  patient. 
However,  very  severe  pain  may  cause  a  local  restriction  of  movement, 
which  is,  in  fact,  to  be  considered  as  a  paralysis. 

Phenomena  of  paralysis;  methods  of  examination.  Paralysis  is 
recognized  by  the  complete  absence  of  the  power  of  motion  in  the 
sense  of  action  of  the  affected  muscles,  and,  as  regards  the  muscle 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  439 

itself,  by  the  absence  of  contraction  that  can  be  seen  or  felt.  An 
extensive  paralysis,  if  it  causes  the  muscles  to  be  lax  (see  below),  pro- 
duces a  characteristic  atonic  behavior  of  the  affected  limb  :  if  Ave  take 
it  up  and  then  let  go,  it  falls  down — an  important  symptom  of  loss  of 
consciousness.  As  regards  those  muscles,  and  there  are  many  such, 
whose  failure  does  not  in  a  very  noticeable  degree  affect  the  motion  of 
a  limb,  because  their  actions  are  replaced  by  others,  we  recognize  the 
paralysis  by  observing  and  feeling  the  muscles  during  active  movements 
of  the  joint  which  would  likely  call  them  into  action ;  among  such 
belongs  the  supinator  longus.  Paresis  is  recognized  by  the  diminu- 
tion of  "native  vigor"  when  resistance  is  called  for;  and  also,  sup- 
posing the  joint  to  be  free  and  an  absence  of  tension  on  the  part  of 
the  antagonizing  muscles,  by  diminished  freedom  and  rapidity  of 
motion.  Again,  we  sometimes  resort  to  an  attentive  examination  and 
careful  feeling  of  the  body  of  the  muscle.  On  the  other  hand,  we  may 
be  deceived  by  the  statement  of  the  patient  that  he  has  a  feeling  of 
lassitude. 

Extent  of  the  paralysis.  Paralysis  of  one-half  of  the  body,  with  or 
without  paralysis  of  the  corresponding  side  of  the  face,  is  called 
hemiplegia.  Paralysis  of  one  side  of  the  face,  of  an  arm,  a  leg,  is 
called  monoplegia  facialis,  brachialis,  cruralis.  We  also  speak  of 
monoplegia  brachio-facialis.  Paraplegia  inferior  is  paralysis  of  both 
legs ;  paraplegia  superior.,  of  both  arms.  Hemiplegia  cruciata  signifies 
paralysis  of  the  arm  of  one  side  and  the  leg  of  the  opposite  side; 
hemiplegia  alternans,  or  likewise  cruciata,  paralysis  of  an  extremity 
of  one  side  and  of  the  facial  or  oculomotorius  of  the  other  side. 

The  extent  of  the  paralysis  is  an  extremely  important  aid  in 
diagnosis,  as  follows  from  the  anatomical  remarks  made  at  the  opening 
of  this  section.     For  anatomical  diagnosis,  see  further  below. 

2.    DISTURBANCE  OF  THE  NUTRITION  AND  TONE  OF  THE  MUSCLES. 

Nutrition  shows  manifest  differences  that  are  very  striking,  and  of 
the  highest  diagnostic  importance.  It  is  determined  by  the  volume 
of  the  muscle  and  by  its  electrical  behavior  (see  Electrical  Examina- 
tion). More  or  less  symmetrical  diminution  in  the  volume  of  the 
muscles  of  a  portion  of  the  limb  is  designated  as  diffuse  atrophy ;  when 
it  affects  a  single  muscle,  as  circumscribed  atrophy.    A  corresponding 


490  SPECIAL  DIAGNOSIS. 

increase  in  the  volume  is  called  hypertrophy  or  pseudo-hypertrophy 
(see  below).  The  existence  of  atrophy,  and  its  extent,  are  determined 
by  inspection  and  palpation  ;  if  possible,  also,  by  measuring.  When- 
ever one  side  alone  is  aflfected,  we  are  always  to  compare  it  with  the 
healthy  side.  Kequiring  the  patient  to  make  active  motion,  by  which 
the  muscle  under  examination  is  made  to  contract,  or  which  causes 
contraction  in  the  surrounding  muscles,  often  makes  the  impression 
much  clearer.  We  can  easily  combine  testing  of  the  strength  with 
the  examination  of  the  state  of  nutrition. 

The  volume  of  an  extremity  is  measured  with  the  tape-measure 
while  the  limb  is  extended  at  rest  (both  arms  and  both  legs  are  to  be 
in  exactly  the  same  position),  and  it  is  best  done  at  certain  points  of 
election. 

We  measure  the  upper  arm  at  the  point  of  its  greatest  circum- 
ference ;  the  forearm,  2  to  3  cm.  below  the  lower  margin  of  the  inner 
condyle  of  the  humerus ;  the  thigh,  15  cm.  above  the  upper  edge  of 
the  patella ;  the  calf  of  the  leg,  at  its  greatest  circumference. 

Thus,  in  measuring  the  forearm  and  the  thigh,  we  must  first  fix 
the  point  where  we  are  going  to  take  the  measure,  and  mark  it  with  a 
blue  pencil. 

Atrophy  is  divided  into  the  following  varieties,  which  are  to  be  very 
sharply  distinguished  from  each  other  : 

(a)  Atrophy  of  inactivity.  This  consists  of  a  diminution  in  the 
volume  of  the  muscles,  which  is  very  slight  and  which  very  slowly 
develops  in  the  course  of  months  of  inactivity.  Almost  without  ex- 
ception, it  supervenes  in  cases  of  paralysis,  and  also  in  any  long- 
continued  inaction  of  the  muscles,  as  in  surgical  diseases  which 
require  the  limb  to  be  kept  at  rest.  In  this  form  of  atrophy,  as  will 
be  shown  later,  the  electrical  sensibility  of  the  muscles  is  qualitatively 
unchanged. 

{h)  Degenerative  atrophy,  with  the  so-called  atrophic  paralysis. 
This  quickly  leads  to  a  high  degree  of  atrophy  of  the  aifected  muscles, 
and  to  a  qualitative  change  in  their  electrical  sensibility — the  reaction 
of  degeneration  (see  below).  This  degenerative  atrophy  only  occurs 
if  the  centre  which  presides  over  the  nutrition  of  the  muscle,  hence 
that  portion  of  the  gray  matter  of  the  anterior  horn  corresponding 
to  the  aifected  muscle,  is  disturbed  or  is  separated  from  the  muscle; 
therefore,  in  all  primary  and  secondary  diseases  of  the  anterior  horns, 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  49I 

in  local   separations    or    interruptions   of    the    connection   with  the 
anterior  roots  or  peripheral  nerves,  in  peripheral  neuritis. 

Here  belong:  poliomyelitis  acuta,  subacuta,  chronica;  progressive 
muscular  atrophy  of  spinal  origin  ;  amyotrophic  lateral  sclerosis ;  all 
processes  within  and  of  the  spinal  cord  Avhicli  destroy  the  gray  sub- 
stance (tumors,  hemorrhages,  softening) ;  compression  of  the  anterior 
roots  and  the  peripheral  nerves ;  traumatic  complete  separation, 
severe  contusion ;  pressure-necrosis  of  these ;  and  all  forms  of  acute 
and  slow  degeneration  or  degenerative  neuritis. 

Also,  it  will  be  understood  (see  above,  p.  456)  that  the  motor  nerves 
below  the  seat  of  the  lesion,  as  far  as  the  muscle,  atrophy ;  see  also 
Electrical  Examination. 

On  the  other  hand,  degenerative  atrophy  is  wanting  in  all  paralyses 
which  are  due  to  a  disease  of  a  motor  tract  above  the  anterior  horn 
ganglia — that  is,  in  the  pyramidal  tract  of  the  spinal  cord,  of  the 
brain,  in  the  cortex  of  the  brain.  Therefore,  in  these  cases,  we  only 
have  the  atrophy  of  inactivity.  Moreover,  degenerative  atrophy  is 
wanting  in  paralyses  of  myopathic  origin  (see  below)  and  in  functional 
paralyses. 

Nevertheless,  degenerative  atrophy  in  many  diseases  occurs  in  such 
a  way  as  to  cause  great  clinical  difficulties  :  the  rapid  (developing 
within  fourteen  days)  diminution  in  the  volume  of  a  muscle,  of  course, 
can  only  occur  when  the  whole  of  the  affected  muscle,  or  a  large 
compact  portion  of  it  is  suddenly,  at  an  approximately  definite  time, 
completely  paralyzed  by  disease  of  the  anterior  horn  or  of  a  peripheral 
nerve  (poliomyelitis  acuta,  section  of  a  nerve,  rheumatic  facial  paral- 
ysis, etc.).  A  disease  developing  slowly,  in  the  course  of  weeks  and 
months,  causes  slowly  progressive  atrophy,  at  first  disseminated  in 
the  separate  muscular  fibres,  only  gradually  becoming  general.  There 
are  also  difficulties  in  determining  the  reaction  of  degeneration  in  such 
slowly  extending  degenerative  atrophy  (see  below)..  We  have  the 
greatest  difficulty  in  making  out  degenerative  atrophy  when  the  dis- 
ease is  a  disseminated  one,  in  which  bundles  of  muscular  fibre  that 
are  still  normal  are  distributed  everywhere  between  diseased  bundles. 
(Regarding  this,  see  further  under  Electrical  Examination.) 

It  is  to  be  remarked  that  all  cachexias  cause  general  atrophy,  as 
well  as  atrophy  of  the  muscles.  But  it  is  worthy  of  still  further  note 
that,  under  the  influence  of  a  general  atrophy,  the  paralyzed  muscles 


492 


SPECIAL  DIAGNOSIS. 


Fig.  151. 


often  become  excessively  atrophied,  even  when  the  atrophy  is  not  a 
degenerative  one.  In  cases  of  myelitis  transversa  and  simple  atrophy 
of  inactivity  of  the  legs,  when  there  comes  to  be  a  general  atrophy, 
we  have  often  seen  the  legs  become  extremely  atrophied,  quite  out  of 

proportion  to  the  volume  of  the  arms. 
But  there  is  no  reaction  of  degenera- 
tion, and  this  fact  furnishes  diagnostic 
assistance. 

It  is  often  extremely  difficult  for 
the  beginner  to  form  a  conception  of 
the  behavior  of  the  anterior  gray  col- 
umns when  there  is  disease  of  a  trans- 
verse section  of  the  spinal  cord,  and 
to  answer  the  question  in  connection 
with  it,  what  sort  of  paralysis  will 
result  from  such  disease.  For  this 
reason  two  examples  are  presented : 

In  a  severe  contusion  of  the  promi- 
nence of  the  neck  (fracture  of  a 
cervical  vertebra,  for  instance)  it  may 
happen  that  the  whole  section  of  the 
anterior  gray  columns,  which  inner- 
vates the  arms,  is  disturbed,  and  that 
simultaneously  the  pyramidal-tract 
fibres  for  the  muscles  of  both  legs  are 
unbroken  (at  S  in  the  figure) :  there 
follows  a  degenerative  atrophic  par- 
alysis of  the  arms  and  a  non-atrophic, 
"  simple  "  (spastic,  see  under  Tonus) 
paralysis  of  the  legs.  The  pyramidal- 
tract  fibres  of  the  latter  degenerate  as 
far  as  the  lumbar  portion  of  the  cord 
(as  far  as  X),  but  the  degeneration 
stops  here :  the  anterior  horn  ganglia 
remain  normal,  and  hence  the  periph- 
eral nerve  and  muscle  also. 
A  myelitis  transversa  of  the  dorsal  portion  of  the  cord  interrupts 
the  pyramidal  tracts  to  the  legs :  these  become  simply  (spastically) 


Schema  of  the  innervation  of  the 
muscles  (partly  from  Edingee).  The 
radiation  of  the  Py-tracts  varies  at 
different  portions  of  the  cortex  (see  p. 
454). 


EXAMINA  TION  OF  THE  NERVOUS  SYSTEM.  493 

paralyzed ;  a  myelitis  transversa  of  the  lumbar  portion  of  the  cord 
disturbs  the  anterior  horn  ganglia  of  the  legs  :  these  are  affected  with 
atrophic  paralysis. 

((?)  Primary  myopathic  atrophy.  This  is  a  disease  of  the  muscle, 
the  nervous  system  being  intact.  It  manifests  itself  by  the  fact  that, 
in  this  disease,  the  muscle  gives  less  response,  corresponding  to  a 
simple  diminution  in  its  volume :  or,  if  it  becomes  completely  shrunken, 
there  is  complete  paralysis  ;  and  further,  by  the  fact  that  the  electrical 
examination,  as  a  rule,  does  not  exhibit  any  trace  of  the  reaction  of 
degeneration.  This  kind  of  atrophic  paralysis  occurs  in  two  quite 
dissimilar  forms : 

{a)  In  muscular  dystrophia  (Erb),  the  myopathic  form  of  progres- 
sive muscular  atrophy  (here  often  combined  with  hypertrophy  or 
pseudo-hypertrophy)  (see  below). 

(h)  In  severe  chronic  diseases  of  the  joints. 

The  parallelism  between  atrophy  and  paralysis  mentioned  above  is, 
moreovei',  generally  present  also  in  degenerative-atrophic  paralyses, 
provided  they  develop  gradually  (subacute  and  chronic).  A  distinct 
disunion  of  atrophy  and  paralysis  occurs  only  in  acute  degenerative- 
atrophic  paralysis  (poliomyelitis  acuta,  injury,  etc.,  of  the  nerve, 
acute  degenerative  neuritis) :  here  the  paralysis  develops  more  or  less 
rapidly,  but  atrophy  only  becomes  manifest  in  the  course  of  weeks. 

Charcot  has  recently  discovered,  in  certain  hystero-traumatic 
paralyses,  a  functional  paralysis  with  more  marked  atrophy,  but 
without  the  reaction  of  degeneration.  But  the  atrophy  here  is  not 
so  decided  as  degenerative  atrophy,  being  rather  between  this  and 
the  atrophy  of  inactivity. 

In  vei-y  exceptional  cases,  when  there  is  disease  of  the  cerebrum, 
particularly  of  its  cortex,  there  has  been  found  a  considerable  mus- 
cular atrophy,  which  appears  early,  sometimes  even  before  the  occur- 
rence of  paralysis,  without  the  reaction  of  degeneration.  In  indi- 
vidual cases  of  this  character,  contractures  were  completely  wanting, 
and  tendon-reflex  was  not  increased. 

Genuine  hypertrophy  of  muscles  occurs  in  Thomsen's  disease 
[general  myopathic  spasm] ;  also  sometimes  in  individual  muscles, 
especially  the  gastrocnemius  muscle,  in  dystrophia  musculorum  ;  here, 
also,  belongs  the  muscular  hypertrophy  which  develops  in  the  sound 
leg  when  one  is  paralyzed  (as  in  long-standing  infantile  paralysis). 


494  SPECIAL  DIAGNOSIS. 

Genuine  hypertrophy  is  recognized  by  the  increased  volume,  great 
hardness,  and  especially  by  the  increased  vigor  of  the  muscle. 

Pseudo-hypertrophy,  on  the  other  hand,  shows  increased  volume, 
but  diminished  power.  This  occurs  in  dystrophia  musculorum  much 
oftener  than  genuine  hypertrophy,  but  it  may  be  developed  from  the 
latter. 

Tonus  of  paralyzed  muscles,  active  spasm,  rigidity  of  muscles. 
An  increased  tonus  of  the  muscles  that  are  paralyzed  (rigidity,  active 
spasm)  is  a  characteristic,  though  sometimes  absent,  sign  of  those 
paralyses  which  are  of  cerebral  or  spinal  origin  above  the  anterior 
horn.  This  tonus  may  be  so  slight  that  the  examiner  will  only  notice 
it  as  a  slightly  increased  resistance  during  passive  motion.  But  it 
may  also  be  so  strong  that  even  when  perfectly  at  rest  a  muscle  is  as 
hard  as  a  board,  and  that  motion  of  a  joint,  in  which  the  muscle 
would  be  extended  (that  is  in  which  the  muscle  would  act  as  an 
antagonizer),  is  entirely  impossible.  Thus  spasm  of  the  quadriceps 
prevents  bending  of  the  knee,  not  only  passive,  but  also  active  bend- 
ing, which,  probably,  if  the  flexing  muscles  were  intact  or  were  only 
paretic,  would  take  place  (spastic  pseudo-paralysis).  Patients  also, 
even  in  slight  degrees  of  rigidity,  experience  great  difficulty  in  making 
active  motions.  That  these  spasms  are  not  due  to  permanent  ana- 
tomical changes  in  the  muscles,  only  to  muscular  contraction,  is 
proved  by  the  fact  that  they  are  sometimes  subject  to  striking  change. 
If  the  paralyzed  muscles  are  spastic  to  a  high  degree,  often  for  a  long 
time  there  does  not  develop  any  atrophy  of  inactivity. 

Paralyses  due  to  affections  of  the  cortex  of  the  brain  usually 
manifest  themselves  by  very  early  spasms.  In  hysteria,  also,  very 
decidedly  active  spasms  occur.  (Regarding  increased  tendon  reflex 
as  an  attendant  phenomenon  of  spasms,  see  p.  497.) 

Atonic  paralysis.  This  is  characterized  by  diminution  or  loss  of 
muscular  tonus,  in  consequence  of  which  there  is  abnormal  passive 
mobility  of  the  joints.  This  laxness  is  present  in  recent  paralyses,  in 
which  the  atrophic,  acutely  degenerative  condition  has  not  yet  devel- 
oped ("atonic  atrophic  paralysis")  It  is  also  found  in  cases  of  chronic 
and  long-standing  degenerative  paralysis  (see  also  under  Contractures). 
Cerebral  paralyses,  as  hemiplegia,  in  rare  cases,  may  also  manifest 
decided  atony.  There  is  a  tolerably  marked  laxness  of  the  muscle, 
without  paralysis,  in  tabes. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  495 

Contractures.  In  long-continued  paralyses,  both  degenerative  and 
simple,  there  develops  in  the  paralyzed  limbs  a  constant  anatomical 
shortening  of  individual  muscles,  and,  indeed,  just  the  muscles  that 
are  chiefly  spastic  often  shorten  in  spastic  paralys's,  but  not  always. 
On  the  other  hand,  in  degenerative  paralysis,  it  is  more  the  antago- 
nizers  of  the  paralyzed  muscles,  or  those  of  the  paralyzed  muscles  that 
are  strongest.  Thus,  from  the  moment  of  paralysis,  the  prevailing 
position,  the  posture  of  the  affected  limb,  gives  the  first  indication  of 
the  development  of  contracture.  These  contractures  do  not  change. 
The  motions  of  the  limb  that  oppose  the  contracture,  and  the  stretch- 
ing of  the  affected  muscles  caused  by  this  motion,  are  very  painful. 

3.    THE  KEFLEXES. 

1.  Skin  Reflex. 

By  this  we  understand  the  quickly  passing  contractions  of  the 
muscles  which  are  caused  by  an  irritation  applied  to  the  skin.  The 
stimulation  of  the  skin  usually  recommended  is  tickling  or  stroking 
it  with  the  blunt  end  of  a  pencil  or  the  handle  of  the  percussion 
hammer.  It  is  well  from  the  beginning  to  aim  at  a  certain  symmetry 
in  the  methods  we  employ ;  only  in  certain  cases,  especially  if  there 
is  diminution  of  the  reflex,  we  may  endeavor  to  call  it  forth  by  prick- 
ing with  a  needle  or  touching  it  with  a  piece  of  ice.  The  skin 
reflexes  about  to  be  mentioned  in  detail  are,  even  in  health,  very 
different  in  different  individuals  (the  cremaster  reflex  relatively  varies 
least) ;  but  upon  the  two  halves  of  the  body  they  are  always  alike. 
Therefore,  where  there  are  unilateral  anomalies  of  it,  the  most  cer- 
tain results  of  trial  of  the  skin  reflex  are  obtained  by  a  comparison 
•with  the  sound  side.  If  we  have  like  results  upon  both  sides  of  the 
body,  then  it  has  only  a  doubtful  diagnostic  value. 

We  are  not  to  confound  with  skin  reflexes  those  motions  that  are 
voluntarily  made.     With  some  practice  they  are  readily  distinguished. 

In  the  face  and  the  upper  extremities,  the  skin  reflexes  are  of  no 
importance ;  on  the  other  hand,  the  three  reflexes  upon  the  legs  and 
abdomen  are  of  especial  diagnostic  significance : 

{a)  The  reflex  of  the  sole  of  the  foot.  This  is  produced  by  irri- 
tating the  skin  of  the  sole  of  the  foot,  and  in  health  consists  either  in 
a  dorsal  flexion  of  the  toes  or  of  the  whole  foot,  or  even  in  motion  of 


496  SPECIAL  DIAGNOSIS. 

the  hip-joint  and  knee.  Pathologically,  the  reflex  may  be  absent 
(weakened  on  one  side  and  increased  upon  the  other).  It  may  be 
increased  with  reference  to  the  amount  of  the  contraction,  with  refer- 
ence to  its  extent,  as  in  simultaneous  contraction  of  the  other  leg, 
motion  of  the  pelvis  or  of  the  whole  body,  for  instance,  as  shorter 
opisthotonus ;  or  it  may  occur  slowly,  or  only  after  repeated  and  con- 
tinued application,  or  summation  of  a  strong  irritation.  It  would  be 
influenced  in  its  form  by  the  tonus  of  the  muscles  of  the  legs :  in  spasm 
of  the  extensor,  for  instance,  often,  instead  of  a  single  motion  of  flexion, 
there  occurs  repeated  trembling. 

(5)  The  cremaster  reflex  in  men  consists  of  a  prompt  upward  motion 
of  the  testicle  from  the  contraction  of  the  cremaster  which  follows  irri- 
tation upon  the  inner  surface  of  the  thigh.  It  is  not  to  be  confounded 
with  the  indolent  contraction  of  the  tunica  dartos  of  the  scrotum, 
which  follows  somewhat  later.  Sometimes  the  cremaster  reflex  is 
extended  to  the  muscles  of  the  abdomen,  causing  the  backward  draw- 
ing-in  of  the  abdomen. 

{c)  Abdominal  reflex.  This  is  a  contraction  of  the  muscles  of  the 
abdomen  [chiefly  the  rectus]  from  irritation  of  the  skin  of  one  side  of 
the  abdomen  [stroking  downward  from  the  edge  of  the  ribsj,  which 
is  recognized  by  an  unilateral  or  a  bilateral  drawing-in  of  the  abdo- 
men ;  when  the  irritation  is  weak,  by  a  slight  displacement  of  the 
navel  toward  the  side  irritated. 

The  figure  explains  the  mechanism  of  the  skin  reflex  :  the  sensible 
irritation  proceeding  from  the  skin  is  conveyed  by  the  motor  fibres  to 
the  anterior  horn ;  but  the  anterior  horn  itself  is  influenced  by  the 
reflex  retarding  fibres  which  pass  in  the  pyramidal  tract.  It  is  clear 
that  the  skin  reflex  must  be  lost  by  an  interruption  of  the  reflex  arc 
at  any  point,  or  by  the  unsusceptibility  of  the  skin,  or  by  myopathic 
paralysis ;  that  it  must  be  increased  with  any  increased  excitability 
of  the  anterior  horn,  or  removal  of  the  restrainino;  reflex  from  the 
brain,  also  in  liypergesthesia  of  the  skin.  Recently,  an  increase  of  the 
abdominal  reflex  upon  one  side  has  been  observed  in  intercostal  neu- 
ralgia (Seeligmiiller). 

We  have  not  mentioned  a  number  of  other  skin  reflexes,  since  they 
are  not  important;  for  pupillary  reflex,  the  reflex  closure  of  the  lids, 
see  under  Examination  of  the  Eye. 

Of  the  reflexes  of  the  mucous  membrane,  the  choking  reflex  when 
the  mucous  membrane  of  the  pharynx  is  tickled  has  diagnostic  sig- 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 


497 


nificance  :  its  absence  is  a  frequent  occurrence  in  hysteria  (anaesthesia 
of  the  mucous  membrane),  also  in  bulbar  paralysis  (nuclear  paralysis). 
Of  very  much  greater  diagnostic  importance  are  the 

2.    Tendon  Reflexes  {^periosteal,  fascial  7'eflex). 

These  reflexes  are  likewise  short  contractions.  They  are  produced 
by  taps  upon  the  tendons  of  muscles,  upon  the  bones  and  fascia,  also 
by  sudden  tension  of  a  tendon  by  a  quick  passive  movement  (in  which, 
however,  the  muscle  itself  is  also  stretched),  Both  the  short  move- 
ment of  the  limb  and  the  momentary  hardening  of  the  muscle  may 
be  made  an  object  of  examination.  In  order  to  develop  the  tendon 
reflex  it  is  necessary  to  have  the  limb  perfectly  relaxed,  and  it  is  well, 
also,  to  divert  the  attention  of  the  patienf. 

Fig. 152 


Diagram  of  the  course  of  the  cutaneous  and  tendon  reflexes.  H,  skin ;  2£,  muscle; 
V,  anterior  horn;  Hi,  posterior  horn;  s,  the  tract  of  the  tendon  reflexes;  h,  the  tract  of 
the  cutaneous  reflexes. 

Whenever  it  is  possible,  a  comparison  is  to  be  made  between  the 
right  and  left  limbs,  but  even  where  this  cannot  be  done,  as  when  the 
disturbance  is  bilateral,  or  the  two  sides  are  disturbed  in  a  similar 
way,  the  greatest  importance  can  be  attached  to  the  result  of  the  test, 
because  here  the  individual  variations  are  not  prominent,  as  they  ar« 

32 


498  SPECIAL  DIAGNOSIS. 

in  the  reflexes  of  the  skin ;  hence  the  tendon  reflexes  are  much  more 
important  aids  in  diagnosis  than  the  skin  reflexes. 

Tendon  and  skin  reflexes  may  be  confounded.  In  a  doubtful  case, 
this  can  be  avoided  by  comparing  irritation  of  the  skin  alone  at  the 
given  points,  by  means  of  pinching,  pricking  a  fold  of  skin,  or  by 
direct  mechanical  muscular  irritation  (see  below.  Biceps-tendon  Re- 
flex); lastly,  as  in  the  skin  reflexes,  by  having  the  patient  take  part 
in  the  examination  by  making  voluntary  contractions ;  these  take 
place  later,  and,  hence,  can  only  deceive  the  inexperienced.  We  may 
be  very  easily  misled  into  supposing  that  there  is  an  absence  of 
tendon  reflex,  if  the  muscles  under  examination  are  not  perfectly 
relaxed. 

We  enumerate  the  tendon  reflexes  according  to  their  importance : 

(a)  Patellar  reflex  (Erb  ;  knee-phenomenon,  Westphal),  consists 
in  a  contraction  of  the  quadriceps.  It  is  caused  by  striking  with  a 
percussion  hammer,  with  the  tips  of  the  semi-flexed  fingers,  or  with 
the  rim  of  the  ear-plate  of  a  stethoscope,  upon  the  patellar  tendon. 
Often  we  must  carefully  seek  the  most  susceptible  point. 

Sometimes  we  may  first  make  the  test  with  the  leg  covered ;  but  if 
the  result  is  in  any  way  doubtful,  then  the  knee  must  be  uncovered. 
Whenever  a  very  exact  examination  is  to  be  made,  the  latter  must 
always  be  done.  In  order  to  get  the  muscles  completely  relaxed,  we 
must  select  certain  positions  :  a  favorable  position  is  to  have  the  limb 
extended  at  rest,  with  the  feet  resting  upon  the  floor ;  another  position 
is  with  the  leg  crossed  over  the  other  in  the  sitting  position  ;  a  third 
is  to  have  the  patient  sit  upon  a  table  with  the  legs  hanging  down ; 
with  the  patient  in  bed,  we  pass  the  hand  under  [the  thigh  just  above] 
the  knee  and  gently  lift  it  up.  As  a  means  of  inducing  patients  to 
relax  the  limb,  they  are  to  be  diverted  by  conversation,  or  they  may 
be  directed  to  close  the  fist  as  tightly  as  possible,  or  sometimes  we 
may  have  them  grasp  the  left  hand  of  the  examiner  or  press  the  hand 
of  someone  else. 

Not  only  active  contraction,  but  possibly  also  increased  tonus  of 
the  quadriceps,  disturbs  the  exhibition  of  the  reflex.  Even  a  patho- 
logically increased  patellar  reflex  may  thus  be  hindered  by  spasm, 
which  must  be  carefully  guarded  against,  Hence,  as  far  as  is  pos- 
sible, we  must  prevent  any  active  spasm  by  the  position  (particularly 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  499 

by  a  cautious  passive  motion)  of  the  knee-joint.     It  may  also  be  inter- 
fered with  by  deformity  and  stiffness  of  the  joint. 

With  very  rare  exceptions,  the  patellar  tendon  reflex  is  always 
present  in  health,  and  both  sides  are  equally  strong. 

The  author  cannot  forbear  saying  that  he  regards  as  impracticable 
the  designation  "  Westphal's  sign"  for  the  absence  of  patellar  reflex — 
notwithstanding  his  very  high  regard  for  the  meritorious  investigator, 
who  is  deserving  of  the  honor — because  this  designation  could  easily 
be  confounded  with  the  opposite  (as,  that  Westphal's  sign  meant 
patellar  reflex). 

(b)  Tendo-Achillis  reflex  and  foot-'phenomenon.  Striking  upon 
the  tendo  Achillis,  and  often  only  on  a  very  limited  portion  of  it,  in 
health,  generally  causes  a  reflex  contraction  of  the  gastrocnemius  (and 
soleus)  with  slight  plantar  flexion  of  the  foot.  In  doing  it,  it  is  best 
to  lift  up  the  foot  by  taking  the  malleoli  with  the  left  hand  (the  foot 
of  course  being  bare). 

By  foot-phenomenon  we  designate  the  contraction  of  the  same 
muscles  if  there  is  a  continuous  contraction,  a  passive  dorsal  flexion 
of  the  foot,  often  best  excited  by  a  quick  passive  motion  (stretching 
the  tendons,  also  the  muscles) ;  a  reaction  then  takes  place  in  a 
series  of  rhythmical  contractions  of  the  plantar  flexors,  or  a  long 
series  of  contractions  :  foot  clonus,  foot-phenomena,  dorsal  clonus. 
This  latter  phenomenon  is  not  really  a  pure  tendon-reflex,  rather  in 
part  it  is  dependent  upon  direct  irritation  of  the  muscles  as  a  result 
of  stretching.  But  it  has  exactly  the  same  diagnostic  significance  as 
increased  tendon-reflex,  for  it  does  not  at  all  occur  in  health,  or,  at 
most,  only  temporarily,  as  when  one  is  very  tired. 

((?)  Tendon  reflex  of  the  upjyer  extremities.  Here  they  do  not  have 
the  same  diagnostic  importance  [as  those  under  (a)  and  (J)],  particularly 
because  they  are  very  often  absent  in  health.  Striking  the  flexor 
tendons  at  the  wrist-joint,  the  biceps  at  the  bend  of  the  elbow,  the 
triceps  tt-ndon  close  above  the  olecranon,  generally  causes  a  slight 
reflex  contraction ;  in  the  two  latter  we  must  be  careful  not  to  strike 
the  muscle  itself.     (See  Mechanical  Irritation.) 

[d)  Periosteal  and  fascial  reflexes  are  elicited  by  striking  the  latter 
and  tlio  li'tnes — the  tibia:  patellar  reflex;  bones  at  the  wrist-joint : 
biceps,  even  pectoralis  reflex.  We  not  infrequently  observe  them  in 
health,  but  very  particularly  when  there  is  increased  tendon  reflex. 


500  SPECIAL  DIAGNOSIS. 

Not  wholly  unimportant,  also,  are  the  bone  reflexes  which  are  manifest 
in  the  muscles  of  the  face  from  blows  upon  the  knee — upon  the  nose; 
they  are  absent  in  bulbar  paralysis,  and  are  present  in  paralysis  of 
the  facial  tract  above  the  bulb. 

The  mechanism  of  the  tendon  reflex  is  made  clear  by  Fig.  152,  p. 
497.  We  see  that  for  its  production  it  is  necessary  to  preserve  the 
integrity  of  the  reflex  arc :  {a)  tendons ;  (h)  sensitive  (that  is,  centri- 
petal) nerve ;  (c)  posterior  root ;  {d)  anterior  horn  ;  (e)  motor  nerve ; 
lastly,  (/)  muscle.  But  we  take  note  of  the  influence  upon  these  of 
restraining  fibres  in  the  pyramidal  tract,  which  may  be  cut  off",  and 
also  may  possibly  be  temporarily  irritated.  Interruption  of  the 
pyramidal  tract  (which  is  manifest  by  its  secondary  degeneration  as 
far  as^  the  anterior  horn)  or  cutting  off"  of  the  pyramidal  tract  by 
primary  degeneration,  causes  increase,  therefore,  of  tendon  reflex,  as 
in  cerebral  paralyses,  spinal  paralyses  from  disease  of  the  pyramidal 
tract,  in  myelitis  transversa,  amyotrophic  lateral  sclerosis,  spastic 
spinal  paralysis ;  but  also  increased  irritability  of  the  spinal  cord  itself, 
as  in  strychnia  poisoning,  tetanus,  lyssa,  neuroses,  and  particularly 
sometimes  in  hysteria.  On  the  other  hand,  the  tendon  reflexes  are 
diminished  or  are  lost :  in  disease  of  the  anterior  horns,  of  the  periph- 
eralnerves,  of  the  posterior  roots  or  their  connection  with  the  anterior 
horns  (poliomyelitis,  spinal  progressive  muscular  atrophy  ;  any  disease 
of  the  peripheral  nerves ;  tabes  dorsalis — here  diagnostically  very  im- 
portant ;  myelitis,  tumors,  hemorrhages,  if  in  certain  locations — that 
is,  if  they  disturb  the  gray  substance  for  the  arm  or  leg). 

It  follows  from  what  precedes  that  the  increase,  and  also  in  many 
respects  the  diminution,  of  the  tendon  reflexes,  goes  parallel  with  in- 
creased or  diminished  tonus  of  the  muscles.  And,  in  fact,  tonus 
seems  to  be  genetically  related  to  tendon  reflexes.  In  this  sense  it  is 
also  of  interest  that  the  predominant  reflexes  of  the  arm  are  the  flexors, 
of  the  leg  the  extensor  of  the  knee,  reflex  of  the  foot,  the  plantar  flexor 
tendo-Achillis,  and  that  exactly  corresponding  with  a  recent  spastic 
paralysis  of  the  arm,  we  are  apt  to  have  flexor  spasm  of  the  arm  and 
extensor  spasm  with  paralysis  of  the  leg  at  the  knee  and  ankle. 

Westphal's  view  [p.  499]  that  the  "  tendon  reflexes  "  are  not 
reflexes,  but  that  they  are  always,  when  ehcited  by  the  prescribed 
methods  of  testing,  due  to  the  direct  irritation  of  the  muscles  by 
stretching  and  concussion,  is  to  be  regarded,  especially  as  respects 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  501 

patellar  reflex,  as  definitely  refuted.  Nevertheless,  we  must  still 
agree  that  the  ordinary  method  of  examination  for  the  foot-phe- 
nomenon in  this  respect  is  not  free  from  objection  (as  has  been  urged 
by  others  also,  as  Jendrassik) :  the  brusque  dorsal  flexion  of  the  foot 
must  necessarily  stretch  the  gastrocnemius — here  it  may  be  due  to 
the  eff"ect  of  stretching  of  the  muscle  added  to  that  of  the  tendon. 

Mixture  of  tendon  reflex  and  direct  muscular  irritation  from  stretch- 
ing the  muscle  probably  also  occurs  in  executing  "  brusque  passive 
motion  "  of  the  limb  (very  quickly  bending  it,  and  extending  the  knee- 
joint,  etc.),  which  is  very  strongly  to  be  recommended  for  determining 
a  slight  degree  of  increased  tonus  of  the  muscles. 

4.    ELECTRICAL    EXAMINATION    OF    THE    NERVES    AND    MUSCLES.^ 

Regarding  the  Physics,  and  the  Instruments  Employed,, 

For  the  electrical  examination  we  employ  the  secondary  or  induc- 
tion current  of  the  faradic  battery  and  the  constant  current  of  a  gal- 
vanic battery.  We  graduate  the  strength  of  the  faradic  current  by 
the  extent  to  which  we  withdraw  the  outer  coil  from  the  inner,  which 
is  reckoned  by  centimetres  and  millimetres  from  the  point  where  one 
coil  is  completely  enclosed  by  the  other,  or  the  distance  between  the 
coils  X  cm. ;  the  strength  of  the  galvanic  current  is  changed  by  im- 
mersing a  different  number  of  elements,  sometimes  more  delicately  by 
a  rheostat.  [The  galvanic  batteries  now  made  in  the  United  States 
and  England  usually  have  a  rheostat  as  a  part  of  the  outfit.  It  is 
much  better  to  use  it,  for  two  reasons :  all  the  cells  of  the  battery  are 
drawn  from  alike,  since  all  can  be  thrown  into  the  current  at  the 
beginning  of  each  sitting;  the  gradations  in  the  strength  of  the 
current  are  made  without  shock  to  the  patient.] 

The  current  is  conveyed  to  the  body  by  an  electrode,  previously 
moistened  with  warm  [preferably  salt]  water.  In  makin"-  the 
examination,  one  of  these  is  always  the  indifferent  one — that  is  to 
say,  it  merely  serves  to  close  the  current  that  is  flowing  through  the 
body;  the  other  is  the  "  diff"erentiating  "  or  examining  one.  The 
first  must  be  as  large  as  possible,  in  order  to  spread  out  the  current 

1  Of  course  it  is  not  necessary  here  to  go  into  particulars.     Hence  we  refer  the  reader 
to  special  works,  particularly  to  Erb's  classical  presentation  in  his  Electro-Therapy. 


502  SPECIAL  DIAGNOSIS. 

over  as  large  a  surface  as  possible  at  the  point  where  there  is  much 
the  greatest  resistance,  namely,  at  the  skin.  The  resistance  is 
inversely  proportional  to  the  cross-section.  Usually,  the  indifferent 
electrode  is  placed  upon  the  sternum.  For  examining  nerves  and 
.small  muscles,  the  examining  electrode  .must  he  quite  small,  in  order 
to  convey  the  current  as  closely  as  possible  to  the  structures,  which 
all  lie  near  the  skin ;  we  cannot  examine  those  lying  deeper.  For 
this  reason,  in  making  the  faradic  examination,  it  is  best  to  select 
the  so-called  "fine''  electrode  of  Erb  (see  Fig.  153).  But  in  em- 
ploying the  galvanic  current,  such  a  small  electrode  would  so  concen- 
trate the  current  by  its  small  cross-section  that  its  passage  through 
the  skin  would  be  too  irritating,  and  hence  we  must  select  for  this 

Fig.  153. 


"Fiae"  electrode  of  Erb  (natural  size). 

current  one  somewhat  larger.  The  size  of  the  electrode  is,  as  already 
said,  of  important  influence  upon  the  intensity  of  the  current  in  its 
transit  through  the  skin  and  a  short  distance  beyond  it,  hence,  also, 
in  that  to  the  stimulating  nerves.  It  is  likewise  not  unimportant, 
for  it  is  very  desirable  to  know,  at  least  approximately  (why,  see 
below),  with  how  strong  a  current  Ave  touch  the  nerves  beneath  the 
skin.  For  this  reason,  and  in  order  that  the  conditions  under  which 
the  examinations,  conducted  by  different  persons,  may  be  as  nearly 
as  possible  alike,  it  is  strongly  recommended  to  employ  a  so-called 
'■'■  normal  electrode."  Unfortunately,  we  have  several,  of  which  we 
•consider  only  the  following :  one  devised  by  Erb,  of  10  sq.cm.  diameter 
{either  square,  3.3  cm.  on  a  side,  or  round  with  a  diameter  of  3.5 
■cm.) ;  and  one  by  Stintzing,  round  and  somewhat  convex,  3  sq.cm.  in 
cross-section  and  2  cm.  in  diameter.  With  every  record  of  an 
examination  there  should  always  be  a  statement  of  the  size  of  the 
electrode  employed. 

We  have  no  absolute  measure  for  the  total  strength  of  the  faradic 
current  in  making  examinations.  Here  we  note  the  distance  of  the 
coils,  but  this,  according   to   the   construction    and   power   of  the 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  503 

apparatus,  may  indicate  different  strengths  of  current ;  nevertheless, 
this  has  value  for  comparison  where  the  examinations  are  made  each 
time  with  the  same  apparatus  (see  below).     For  the  galvanic  current 

V       A^    *  X  1  volt 

we  have  an  absolute  measure  :  the  milliampere  (M.-A.),  =  -TaKa — r — • 

(See  text-books  upon  Physics.)      To  ascertain  the  number  of  milli- 

amperes  used,  we  employ  a  so-called  absolute  galvanometer.     The 

total  strength  of  current  as  given  by  the  galvanometer  is  then  divided 

by  the  transverse  section  of  the  examining  electrode  in  such  a  way 

that,  for  example,  with  a  total  strength  of  2.5  M.-A.  and  an  electrode  of 

2.5 
12  sq.cm.  transverse-section  to  a  sq.cm  ,  a  current  of  jo  M.-A.  is  given 

off  (N. B.,  to  a  sq.cm.  of  the  skin);  the  density  of  the  current  in  the 

nerves  examined  is  not  exactly  proportional  to  that  in  the  skin  (see 

below).     Hence,  this  fraction  has  no  exact  value  as  such — rather  only 

as  a  brief  expression  of  the  two  figures  which  we  have  to  consider. 

If  we  employ  a  normal  electrode,  then  we  can  note :  Norm,  electrode 

2  5 
Erb  (10  sq.cm.)  2.5  M.-A.,  or  ~  M.-A.  (N.  el.  Erb). 

This  comparison  of  the  total  strength  of  the  current  with  the 
absolute  measure  is  nowadays  indispensable ;  it  has,  it  is  true,  only  a 
value  which  is,  in  a  certain  sense,  circumscribed.  A  difficulty  which 
at  present  is  tolerably  successfully  overcome,  consists  in  the  fact  that 
the  conducting  resistance  of  the  skin,  for  various  reasons,  declines, 
and  with  it,  although  only  in  a  slight  degree,  the  strength  of  the 
current  increases,  while  the  electrodes  rest  upon  the  body,  and 
hence,  also,  from  the  moment  when  the  galvanometer  is  switched-in 
to  the  instant  when  the  needle  comes  to  rest.  This  space  of  time 
in  the  new  galvanometers  (especially  Edelmann's  horizontal  galvano- 
meter, but  also  with  the  instruments  of  Bottcher-Stohrer  and  Hirsch- 
mann),  by  appropriate  checks,  is  satisfactorily  shortened.  Stintzing 
is  to  be  credited  with  very  exact  examinations  regarding  these 
points. 

A  much  more  considerable  diflBculty,  and  one  which  probably  will 
never  be  entirely  overcome,  consists  in  the  fact  that  we  cannot  con- 
centrate our  current  upon  the  nerve  (muscle)  to  be  examined,  because 
it  lies  in  tissue  which  itself  is  a  good  conductor,  and  that  from  the 
total  strength  of  the  current  and  the  cross-section  of  the  conductor  of 


504  SPECIAL  DIAGNOSIS. 

the  current  into  the  skin  we  can  only  approximately  determine  the 
current  which  enters  the  nerve  (muscle)  itself.  For  this,  there  are  two 
chief  reasons :  first,  because  the  situation  of  the  nerve  with  reference 
to  the  skin  varies  with  each  individual  (layer  of  fat,  anatomical 
peculiarities) ;  and  because,  from  the  situation  of  the  nerve,  the  frac- 
tion of  the  current  which  enters  it  is  intrinsically  changed.  (Even 
the  quality  of  the  contractions  caused  by  the  current  will  be  influenced 
by  the  relation  of  the  nerve  to  the  skin. — Erb.)  Further,  since  the 
nerve  offers  a  quite  considerably  stronger  resistance  to  the  current  if 
it  enters  it  at  a  [right]  angle  to  its  axis,  than  if  it  flows  along  its 
axis,  the  angle  at  which  the  current  enters  the  nerve  will  consider- 
ably affect  the  strength  of  the  current ;  and  we  cannot  accurately 
measure  this  angle  in  the  case  of  all  nerves. 

There  follows  from  the  foregoing,  first  of  all,  the  practical  point 
that,  in  spite  of  our  ability  to  measure  the  strength  of  the  total 
current,  we  are  taught  to  bear  in  mind  the  individual  peculiarities  of 
the  nerves  (muscles)  to  be  examined,  in  their  relation  to  the  skin,  in 
interpreting  the  results  of  the  examination,  so  as  to  supply,  as  far  as 
possible,  the  want  of  exactness  in  our  calculation ;  and  it  follows, 
further,  that  it  is  superfluous,  and  even  a  source  of  error  (because  it 
withdraws  our  attention  from  the  more  important  points  of  view),  if 
we  strive  after  exactness  in  electrical  examination  by  the  fineness  of 
the  apparatus,  especially  of  the  galvanometer — an  exactness  which, 
let  it  be  said  once  for  all,  the  examination  cannot  have.  Of  what  use 
is  it  exactly  to  determine  the  strength  of  the  total  current  to  within 
one- tenth  of  a  M.-A.,  when  we  do  not  exactly  know  how  much  of  the 
total  strength  the  real  objects-  of  our  examination — the  nerves — 
receive  ? 

JIoiv  to  distinguish  the  poles  quickly.  In  the  faradic  current  the 
poles  come  but  little  into  consideration,  namely,  only  so  far  as  to 
know  that  the  cathode  (negative  pole)  of  the  opening  current  of  the 
secondary  coil  has  a  stronger  irritating  effect  than  the  anode.  In 
the  galvanic  current,  the  poles  are  widely  different,  and  hence  it  is 
important  to  distinguish  them  quickly  upon  the  apparatus.  The 
simplest  way  is  to  employ  a  very  mild  current,  and  then  to  place  the 
two  electrodes  upon  the  cheeks ;  upon  the  side  of  the  anode  we 
experience  a  peculiar  indefinable  taste  upon  the  tongue  and  the 
mucous  membrane  of  the  cheek  of  that  side ;  or  we  place  the  wires 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  505 

of  both  poles  about  1   cm.  apart  upon  a  piece  of  wet  blue  litmus 
paper  :  the  anode  colors  it  red. 

By  a  current- changer  we  are  able  to  reverse  the  poles — that  is,  to 
quickly  make  the  anode  the  cathode,  and  vice  versa. 

Methods  of  Examination   and  their  Physiological  Results 
UPON  THE  Living  Human  Body. 


As  a  foundation  to  what  is  here  to  be  spoken  of,  we  refer  most 
urgently  to  the  text-books  upon  physiology  or  upon  electro-ther- 
apeutics, especially  to  what  is  taught  regarding  electrotonus  and 
the  laws  of  contraction  (Pfliiger),  Unfortunately,  we  cannot  enter 
upon  these  subjects  here ;  only  remarking  that  the  results  of  the  ex^ 
amination  upon  uninjured  animals  and  men  diifer  from  the  physio- 
logical results,  and  for  physiological  reasons,  which  cannot  here  be 
explained.  [The  student  is  referred  to  Landois  and  Stirling's  Phj- 
siology,  section  336,  for  an'  excellent  presentation  of  Electrotonus — 
law  of  contraction.] 

The  electrical  examination  consists  of  an  irritation  of  a  nerve  (indi- 
rect irritation)  as  well  as  of  the  muscle  (direct  irritation),  one  of 
which,  indeed,  takes  place  with  both  kinds  of  current,  and  in  observing 
the  effect  of  the  irritation,  as  it  is  manifest  by  muscular  contraction. 
Thus,  we  have  to  make  use  of  an  indirect  faradic  and  galvanic  and  a 
direct  faradic  and  galvanic  examination.  As  previously  stated,  the 
extent  of  the  irritation  is  always  a  matter  of  uncertainty  to  us  (dis- 
tance of  the  coils ;  total  strength  of  the  galvanic  current  in  M.-A.). 
We  draw  our  conclusions  from  the  results  of  the  examination  : 

{a)  From  the  degree  of  excitability  of  the  nerve  (muscle),  by  deter- 
mining with  what  strength  of  current  there  follows  the  first,  small- 
est, just  noticeable,  or  minimal  contraction;  or  also  by  determining 
the  extent  of  irritation  which  is  necessary  with  the  galvanic  examina- 
tion to  cause  a  tetanic  contraction.  The  minimal  contraction  is 
observed  at  the  muscle,  or  by  the  movement  of  the  joint.  The  com- 
prehension of  these  minimal  contractions  (still  more  of  galvanic  teta- 
nus— see  below)  by  the  individual  examiner  is,  to  a  certain  extent, 
variable,  and  a  source  of  inexactness. 

(6)  With  reference  to  the  quality  of  the  reaction  in  the  direct  irri- 


506  SPECIAL  DIAGNOSIS. 

tation  of  the  muscle  with  the  galvanic  current,  that  is,  the  character 
of  its  contractions  and  its  "  law  of  contraction"  (see  below). 

Since  the  electrical  currents  only  stimulate  by  sudden  oscillations 
in  the  current  (except  it  be  very  strong),  the  faradic  current,  because 
it  consists  of  a  great  number  of  opposing  currents  of  short  duration, 
causes  a  tetanic  contraction  proceeding  from  the  nerve  as  well  as 
from  the  muscle  itself,  which  continues  while  the  electrode  remains 
with  the  current  closed  ;  the  galvanic  current,  on  the  other  hand^ 
indirect  as  well  as  direct,  produces  its  effect  only  at  the  instant  of  its 
entrance  :  contraction  from  closino:  the  current,  and  at  the  instant  of 
its  exit :  contraction  from  opening  the  current.  But  while  with  the 
nerve  exposed  (Pfliiger)  at  the  cathode  [represented  hereafter  by  Ca] 
(negative  pole),  only  the  closing  of  the  current,  and  at  the  anode 
[represented  hereafter  by  An],  only  the  opening  of  the  current  occa- 
sions a  contraction,  we  find  that  with  the  nerves  and  muscles  of  the 
living  man  there  is  another  law  of  contraction  (explained  in  works 
upon  electro-therapy). 

G-eneral  Methods,  and  Explanation  of  the  Terms  Mmployed  in 
Cralvanic  Examinations. 

The  indifferent  electrode  stands  upon  the  sternum,  the  examining 
electrode  (normal  electrode)  upon  the  nerve  (muscle).  With  the 
current-changer  we  close  the  current  so  that  the  examining  electrode 
is  the  cathode — that  is,  we  make  the  "cathodal  closure"  CaS  [S  = 
Schliesung,  closure]  ;  there  results  a  contraction,  C,  thus  it  is  CaSC  ; 
then  we  open  the  current,  thus  making  a  cathodal  opening,  CaO: 
sometimes  there  is  CaOC ;  then  we  reverse  and  close  the  current, 
so  that  the  examining  electrode  becomes  the  anode,  An,  making 
AnS :  we  sometimes  have  AnSC,  then  likewise  at  the  end  AnOC. 
With  a  very  strong  current  we  have  upon  CaS,  and  with  the  current 
remaining  closed,  a  tetanic  contraction :   CaSTe. 

Laws  of  normal  contraction  with  galvanic  stimulation: 
1.  Nerve  : 

(a)  Weak  current :  feeble  CaSC, 

CaO  :  negative, 
AnS  : 
AuO :         " 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  507 

(b)  Stronger  current :  strong  CaSC, 

CaO  :  negative, 

AnSC, 

AnOC. 

(c)  Very  strong  current :   CaSTe, 

feeble  CaOC  (not  always), 
*  strong  AnSC, 

strong  AnOC. 

That  is,  with  a  weak  current  there  is  only  CaSC,  with  a  strong  one 
also  AnSC,  and  about  at  the  same  time  AnOC,  with  very  strong, 
CaSTe,  and  sometimes  CaOC. 

The  contractions  are,  all  of  them,  short,  lightning-like. 

2.  Muscle,  irritated  at  a  place  where  there  is  no  nerve,  or,  at  least, 
irritated  as  little  as  possible  (at  a  distance  from  the  "  motor  point," 
the  place  where  the  nerve  enters,  see  below) : 

Moderate  current :  CaSC, 

Only  a  little  stronger  :  AnSC. 

The  contractions  of  opening  the  current  are  subordinate,  often  entirely 
wanting.  The  contractions  mentioned  as  occurring  at  the  closure  are, 
indeed,  short,  but  yet  not  so  lightning-like  as  those  from  an  exposed 
nerve. 

Method  of  ^Examination  in  Detail.     Normal  Condition. 

Preliminary  remarks.  In  examining  individual  nerves  and  muscles 
we  must  strive  most  earnestly  to  employ  exactly  similar  methods.  In 
the  first  place,  in  examining  nerves,  we  should  use  Erb's  fine  electrode 
for  the  faradic  current,  and  either  Erb's  or  Stintzing's  normal  elec- 
trode for  the  galvanic  current.  With  the  galvanic  current,  especially, 
we  should  always  make  about  the  same  pressure  upon  the  electrode, 
increasing  the  pressure  only  when  there  is  a  very  firm  layer  of  fat  (in 
order,  in  this  way,  to  equalize,  to  some  extent,  the  eifect  of  the  fat 
layer).  We  are  always  to  examine  homonymous  parts  together,  that 
is  the  right,  then  the  left  radial,  the  right,  then  the  left  median,  or, 
when  the  disease  is  unilateral,  the  nerve  (muscle)  of  the  sound  side 
always  first. 


508 


SPECIAL  DIAGNOSIS. 


1,  Points  of  Stimulation, 

In  what  follows  we  give  the  points  of  stimulation  of  the  nerves 
and  the  so-called  motor  points  of  the  muscles  (studied  by  Duchenne, 
Ziemssen,  Erb — the  illustrations  from  Erb's  Electro- TJierapeutics), 
which  chiefly  correspond  to  the  points  where  the  nerves  enter  the 
muscles,  and  hence  are  essentially  also  the  nerve-points.  In  e^am- 
inino-  the  muscles  themselves  Ave  place  the  electrode  upon  the  fleshy 
part  of  the  muscle,  avoiding,  as  far  as  possible,  both  of  these  related 

points. 

Fig.  154. 


M.  frontalis. 

tipper  branch  of 
facial. 

M.  corrug.  snpercil. 


M.  orbic.  palpebr. 

Muscles  of  the  \ 

nose.  \ 

M.  zygomatici. 


M.  orbicul.  oris. 


Middle  branch  of 

facial. 

M.  masseter. 

31.  levator  menti. 

M.  quadr.  menti. 

M.  triang.  menti. 

N.  hypogloss. 

Lower  branch  of 

facial. 

M.  piatysma  myoid. 

Muscles  of  the  root  ( 
of  tongue.  ( 


M.  omohyoideus. 


!N.  thoracic, 
anter.  (M.  pector.) 


N.  phrenicus. 


Plexus 
brachialis. 


Region  of  central 
convolution. 


Region  of  the  third 
frontal  convolution. 

M.  temporalis. 

Upper  branch  of 
facial  in  front  of  ear. 
N.  facialis  (Stamm). 

X.  auricul.  post. 

Middle  branch  at 

facial. 
Lower  br.  of  facial. 
M.  splenius. 

M.  sterno-cleido- 

mastoideus. 
Jf.  accessorius. 
M.  levator  anguli 
scapul. 

M.  cucullaris. 
N.  dors,  .scapulae. 


Jf.  thoracic,  long. 

(M.    serratus    antic. 

maj.) 


Supraclavicular 
point.  (Erb's  point. 
M.  deltoid.,  biceps, 
brachial,  intern,  and 
supinat.  long.) 

Points  of  Electrical  Irritation  upon  the  Head  and  Neck.     (Ere.) 

The  points  most  distinct  in  the  figure  correspond  to  the  chief  places 
for  applying  the  stimulation.     In  the  faradic  examination,  we  seek 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 


509 


carefully  in  the  course  of  the  nerve  for  these  most  excitable  points 
(that  is,"^  of  course,  for  those  places  where  they  lie  nearest  the  skin). 
Remarks  regarding  Fig.  154  :    We  observe  particularly  the  upper, 


Fig.  155. 


W.  triceps  (caput  longuni)    — 


iti. triceps  (caput  iDtern.) 


Nerv.  ulnaris  \ 


if.  flexor  carpi  ulnaris 

II.  flex,  digilor.  commun. 
profund. 


]tl.  flex,   digitor.  sablim. 
(digit!  U  et  11/) 

jU.  flex,  digit,  snbl.  (digit, 
indicis  et  minimi) 

Nerv.  -ulnaris 


U.  palnaris  brev. 

M.  abductor  digiti  min. 

M.  flesor  digit,  min 

M.  opponens  digit,  min. 

Mi.  lum'uricales  \  - 


M.  deltoidbua 


Nerv.  musealo- 
cutaneui 

il.  biceps 
brachii 

M.   bracli. 
inteinas 


I  Nerv.  medianut 
M.  supinator  longns 

a.  pronator  teres 

■  M.  flci.  carpi  radialis 

M.  flex,  digitor.  sablini. 

M.  flex.  polJicis  longua 
Nerp.  medianus 

M.  abductor  pollio.  brer. 
M.  opponens  pollicis 

M.  -flex.  poll.  brev. 

M.  adductor  pollic.  brer. 


Points  of  Electrical  Irritation  upon  the  Arm.     \  Eeb. 


510 


SPECIAL  DIAGNOSIS. 


middle,  and  lower  facial  (the  three  most  distinct  points  upon  the  face). 
At  the  brachial  plexus  we  notice  Erb's  point  [the  supra-clavicular 
point]. 


Fig.  156. 


M.  deltoid eus 


M.  eitensor  digit,  communis  [    • 

Hi.  extensor  indicia 
M.  a1)dactor  pollic,  long. 
M.  extensor  pollic.  brev. 


M.  interoES.  dorsal.  I  et  11  | 


M.  'triceps  (caput  longam) 


I  M.  triceps  (caput  extern.) 


H,  brachial,  intern.  - 

M.  supinator  long. 
M.  radial,  est.  long. 
M.  radial,  est.  brev. 


M.  ulnar,  extern. 
M.  supinat.  bier. 

M.  extens.  digiti  minim. 
M.  extens.  indicis 

M,  extens.  poll.  Ipng. 


M.  abduct,  digit,  min. 


U.  interosE.  dorsal. 
Ill  et  IV. 


Points  of  Electrical  Irritation  upon  the  Arm.     (E^b.) 

2.  Examination. 

The  tongue  and  soft  palate  will  be  best  directly  irritated  with  an 
electrode  that  is  isolated  as  far  as  to  the  end  (which  may  be  done  by 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 


511 


simply  winding  it  with  adhesive  plaster),  A  strong  galvanic  current 
should  never  be  used  upon  the  head. 

Remarks  regarding  Figs.  155  and  156  :  We  examine  the  arm  in 
the  position  of  moderate  flexion  and  slight  pronation,  but  the  muscles 
are  to  be  relaxed  (hence,  the  arm  must  rest  upon  something). 

The  radial  nerve  lies  deep,  especially  if  the  muscles  are  well 
developed.  We  can  generally  follow  with  the  finger  the  ulnar  nerve 
upward  from  the  sulcus  of  the  internal  condyle  of  the  humerus. 

Remarks  upon  Figs.  157,  158,  159  (pp.  511-514) :  It  is  very 
difficult  to  stimulate  the  ischiatic  nerve.      It  can  only  be  done  by 

Fig.  157. 


U.  adductor  magnus 
U.  addnci.  longvs 


M.  tensor  fasciae  latae 

M.  sariorins 

M.  quadriceps  femoris 

U.  rectus  femoris 


Tastus  ezternns 


AI.  vastus  internus 


Points  of  Electrical  Irritation  upon  the  Upper  Part  of  the  Thigh.     (Erb.) 


pressing  the  electrode  in  deeply  and  employing  a  strong  current. 
We  can  easily  find  the  peroneus  nerve,  if  we  feel  for  the  head  of  the 
fibula  and  go  inward  and  upward  from  this. 

Upon  the  back,  since  the  nerves  almost  nowhere  lie  sufficiently 


512  SPECIAL  DIAGNOSIS. 

near  the  surface  to  permit  of  the  indirect  examination,  we  have  to  do 
almost  exclusively  with  direct  muscular  irritation.  It  is  superfluous 
to  make  more  exact  statements  regarding  the  simple  topographical 
relations. 

We  demonstrate  this  upon  a  single  nerve-muscle,  and  for  this  we 
take  the  radial.  We  always  begin  with  the  faradic  current,  and 
this  for  good  reasons,  which  have  recently  been  made  more  strong 
(relations  of  the  "resistance  to  conduction  " — Stintzing),  which  we 
cannot  enter  upon  here. 

(a)  Faradic  Examination. 

(a)  Nerve.  The  indifferent  electrode  is  placed  upon  the  sternum, 
the  examining  electrode  (the  fine  one  of  Erb),  held  as  a  pen  in  writing, 
is  placed  upon  the  radial  nerve  [musculo-spiral],  where  it  turns  around 
the  humerus  at  the  middle  of  the  arm :  here  tolerably  deep  pressure 
is  necessary.  The  induction-coil  is  to  be  pulled  out  till  the  minimal 
contraction  is  produced,  and  the  distance  to  which  it  is  removed  is 
read  off  and  noted.  Thus  will  we  feel  for  the  nerve  with  the  elec- 
trode: the  minimal  contraction  takes  place  at  the  instant  we  pass 
over  the  nerve.  Next,  there  is  to  be  determined  the  '^  conductive 
resistance"  at  that  particular  spot:  we  employ  the  galvanic  current; 
we  apply  a  well-moistened  normal  electrode;  a  definite  number  of 
elements  of  the  battery  is  inserted ;  we  read  off  and  note  down  the 
figures  of  the  galvanometer  in  M.-A.  The  galvanometer  is  to  be 
read  when  the  electrode  has  been  upon  the  nerve  for  just  thirty 
seconds. 

It  is  necessary,  in  our  opinion,  to  determine  the  "conductive  re- 
sistance" exactly  in  the  manner  described  by  Erb.  The  fluctuations 
in  the  conductive  resistance,  and  with  it  (in  an  opposite  sense)  the 
strength  of  the  total  current,  are  in  fact,  during  the  examination,  very 
slight,  and  can  ordinarily,  as  has  been  shown  most  accurately  by 
Stintzing,  be  neglected.  But,  in  some  cases,  it  happens  that  at  the 
point  of  examination  the  skin  is  very  tender,  or  abnormally  dense  ;  in 
which  case,  of  course,  with  the  same  separation  of  the  coils  of  the 
same  apparatus,  we  have  relatively  a  stronger  or  relatively  a  weaker 
current ;  and  we  obtain  a  minimal  contraction  with  a  large,  or  with 
only  a  very  slight,    conductive    resistance.      This    result  we  would 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 


513 


refer  to  an  increased  or  dirainished  irritability  of  the  nerve  if  we 
had  not  ascertained  by  the  galvanic  determination  of  the  "  con- 
ductive resistance "  that  the  skin  was  the  cause  of  the  variation. 
Extremely  instructive  examples  illustrating  this  point  are  given  by 
Erb  in  his  Electro- TherapeMtics. 

Fig.  158. 


m  \ 

IM    J  M.  glntaeus  iiiasimus 


Nerv.  ischiadicus 

M.  ticeps  fein.  (cap.  long.) 
M.  biceps  fem.  (cap.  brev.) 


jff.  peroneus 
M,  gastrocnem.  (cap.  extern.} 

M.  soleus 
M.  fle.\or  hallucis  longus 


M.  adductor  maguus 
M.  semitendinosus 
M.  semimembranosns 


X.  tibialis 

II.  gastrocnam.  (cap.  int.) 
M.  solens 

M.  flexor  digitor,  comm.  longus 


Points  of  Electrical  Irritation  upon  the  Back  of  the  Lower  Extremity.     (Erb  ' 

In  other  words  :  whenever  we  are  making  an  electrical  examina- 
tion, we  must  know  what  strength  of  total  current  we  are  employing. 
Since  we  are  not  able  to  determine  this  directly  with  reference  to  the 

33 


514 


SPECIAL  DIAGNOSIS. 


faradic  current,  we  must  endeavor  to  form  an  opinion  of  the  total 
strength  of  the  faradic  current  (with  a  certain  definite  separation  of 
the  coils)  by  bearing  in  mind  the  total  strength  of  the  galvanic  current 
which  is  caused  by  a  certain  number  of  elements  (always  the  same). 


Fig.  159. 


M.  tibial,  antic. 

M.  extens.  digit,  comni. 
long. 


M.  peroneus  brevis  * 


M.  extensor  hallucis 
long. 


1M.  interossei  dorsalss 


Nerv.  peroneus 

M.  gastrocnem.  eistero. 
M.  peroneus  longns 


M.  solens 


M.  flexor,  liallacis  long. 


M.  extens.  digit,  comm. 

brovis 


M.  abductv  digiti  min. 


Points  of  Electrical  Irritation  upon  the  Leg.     (Erb.) 


If  we  examine  at  the  same  time  a  number  of  nerves,  we  first  de- 
termine the  minimal  contraction  for  all,  and  then  the  conductive 
resistance ;  and,  after  we  have  examined  the  nerves,  we  can  at  once 
make  the  faradic  examination  of  the  muscles. 

It  is  always  well  to  follow  the  faradic  examination  with  the  galvanic, 
and  in  this  way,  with  a  good  deal  of  practice,  we  can  form  an  opinion 
regarding  the  relation  of  the  conductive  resistance  at  the  different 
points  of  stimulation  of  the  nerves,  and  can  make  a  counter  judgment 
regarding  the  faradic  result  by  a  comparison  of  the  number  of  ele- 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  515 

ments  used  each  time,  and  tlie  absolute  strength  of  current  that  is 
obtained.  But,  then,  there  must  always  be  given  in  the  record  of  the 
galvanic  examination  both  the  number  of  elements  and  the  strength 
of  the  current  in  M.- A. 

We  wish  that  the  direction  given  above,  that  the  galvanometer 
should  be  read  when  the  electrodes  have  been  in  place  just  thirty 
seconds,  could  be  carried  out  in  all  efforts  at  electro-diagnosis,  because 
otherwise  the  marked  increalse  of  the  current  at  the  beginning,  just 
after  the  electrodes  have  been  applied,  could  easily  occasion  great 
inequalities. 

(/?)  Muscles  supplied  hy  the  radial  \jnusculo-spiraT\  nerve.  We 
use  a  somewhat  larger  electrode,  stimulate  the  fleshy  part  of  the 
individual  muscles,  and,  lastly,  determine  the  minimal  contraction ; 
the  determination  of  the  conductive  resistance  is  not  necessary. 

Under  some  circumstances,  there  comes  into  consideration  the 
quality  of  the  muscular  contraction  in  indirect  and  direct  faradic 
stimulation.     (See  under  Reaction  of  Degeneration.) 

{h)   Gralvanic  Examination. 

(«)  Nerve.  Place  the  indifferent  electrode  upon  the  sternum  and 
the  examining  electrode  (with  somewhat  strong  pressure)  upon  the 
radial  [musculo-spiral]  nerve  where  it  passes  around  the  humerus ; 
close  the  cathode  three  times  ;  if  the  result  is  negative,  increase  the 
number  of  elements  :  again  close  the  cathode  three  times,  and  so  on 
until  the  minimal  contraction  is  found.  Then  switch-in  the  galvanom- 
eter and  read  off  the  strength  of  the  total  current.  (Galvanometers 
that  have  a  very  good  arrangement  for  damping  the  vibration  of 
the  needle  can  remain  switched-in  during  the  examination.)  Now 
determine  the  minimal  AnSC  in  the  same  way  (but  it  may  be 
omitted).  Usually  we  may  be  satisfied  with  this.  The  next  point  of 
interest  would  be  the  determination  of  CaSTe.  (Regarding  varia- 
tions in  the  quality  of  the  reaction,  see  under  Reaction  of  Degenera- 
tion.) 

(/5)  Muscles  of  the  radial.  We  proceed  as  in  the  case  of  the  nerves, 
but  sometimes  we  may  place  the  indifferent  electrode  upon  the  wrist, 
dorsal  side,  etc.  It  is  always  necessary  to  determine  the  minimal 
CaSC  and  minimal  AnSC  ;   but  before  all,  the  most  exact  observance 


516  SPECIAL  DIAGNOSIS. 

of  the  character  of  the  contraction  (see  under  Reaction  of  Degenera- 
tion), whether  it  is  "  lightning-like  "  or  "  slow,"  and  in  this  direction 
we  not  only  observe  the  minimal  contraction,  but  also  whether  it  is  a 
stronger,  or  a  strong,  contraction. 

Summarized,  the  scheme  of  examination  would  be  as  follows : 

(a)  Faradic  examination : 

(a)  nerve 
(/5)  muscle 

(b)  Galvanic  examination : 

(«)  nerve 
(/5)  muscle. 

3.    What  to  Observe  in  Determining  the  Electrical  Reaction. 

We  examine  in  two  main  directions :  (a)  the  quantitative  excita- 
bility, or  degree  of  excitability  of  the  nerves  and  muscles;  (5)  the 
qualitative  excitability  of  the  muscles  under  galvanic  stimulation. 

{a)  Quantitative  excitability.  Its  diminution  in  the  most  marked 
degree,  namely,  loss  of  excitability,  is  easily  recognized.  To  the 
record  is  always  to  be  added  :  "  lost  when  the  coils  of  the  induction 
apparatus  were  separated  to  a  distance  x,  or  for  a  current  of 
X  M.-A."  On  the  other  hand,  it  is  difficult  to  define  the  limits  be- 
tween the  normal  and  pathological  in  simple  diminished  or  increased 
excitability,  particularly  of  the  nerves.  We  can  take  different  ways 
to  arrive  at  a  conclusion  in  this  regard  : 

(«)  We  compare  the  two  halves  of  the  body — very  much  the  most 
certain  way,  but  of  course  only  applicable  in  cases  of  unilateral  disease. 
Normally,  the  difference  between  the  two  halves  of  the  body  is  very 
slight.  The  maximal  differences  for  the  nerves  and  with  the  galvanic 
current,  according  to  Stintzing  (58  healthy  persons ;  Stintzing's  normal 
electrode  of  3  sq.cm.),  are  : 

Earn,  frontal.  N.  VII 0.7  M.-A. 

N.  accessorius 0.15     " 

N.  medius 0.6       " 

N.  ulnaris  2''  above  the  olecranon  0.6       " 

For  faradic  excitability  the  difference  for  the  two  sides  of  the  body, 
at  least  for  the  four  pairs  of  nerves  that  come  especially  into  consider- 
ation, rami  frontal,  (facial.),  N.  accessorius,  ulnaris,  peroneus  (see 
below)  is,  according  to  Erb,  scarcely  ever  greater  than  10  mm.  separa- 
tion of  the  coils  of  his  Dubois  induction  apparatus ;  according  to 


N.  radialis 1.1  M.-A. 

N.  peroneus o    0.5      " 

IT.  tibialis 1.1       ■' 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 


517 


Stintzing  the  maximal  difference  of  all  the  pairs  of  the  body  that  are 
accessible  for  examination  is  15  mm. 

A  difference  which  approaches  this  maximal  difference  must  lead 
one  to  think  of  a  pathological  condition  ;  a  difference  that  is  materially 
greater  is  certainly  pathological.  But  whenever  a  difference  is  found, 
we  must  always  consider  whether  the  two  homonymous  nerves  are 
situated  exactly  alike  (malformation  of  the  bones,  etc.,  see  above). 

(/5)  We  are  to  observe  the  relation  which  exists  between  the  irri- 
tability of  the  N.  frontalis  (facialis),  accessorius,  ulnaris  (at  the 
elbow),  peroneus  :  according  to  Erb's  method. 

These  nerves,  but  especially  the  ulnaris  and  peroneus,  show  only 
slight  differences  in  health,  as  the  following  table,  taken  from  Erb's 
Hajidbook,  shows : 

Faradic  Current. 


1.  Healthy  person,  mechanic,  age  thirty-eig 

bt  years. 

Distance  of  coils  in  mm., 
minimal  contractions. 

Variation  of  galvanom.  (old  one), 
10  elements. 

N.  frontalis      .... 
N.  accessorius      .     .    . 

N.  ulnaris 

Is.  peroneus     .... 

r.  165 
172 
159 
160 

1.  166 
177 
158 
163 

r.  18° 

16° 

6° 

7° 

1.  19° 
15° 

6° 
9° 

2.  Healthy  person,  laborer,  age  twenty-four  years. 


Distance  of  coils  in  mm.. 

Variations  of  galvanometer 

minimal  contraction. 

(old  one),  10  elements. 

N. 

frontalis      .... 

r.  195 

1.  192 

r.  17° 

1.17° 

N. 

accessorius       .     .     . 

187 

182 

10° 

9° 

N 

ulnaris 

135 

185 

6° 

10° 

N. 

peroneus     .... 

180 

180 

5° 

5° 

G-alvanic  Current. 

Healthy  men,  thirty-eight  to  twenty-four  years  of  age. 
electrode,  10  sq.cm.) 


(Normal 


R.  frontalis 
K.  accessorius 
N.  ulnaris   .     . 
N.  peroneus     . 


Occurrence  of  the  first 
CaSE. 


1.4  M. 
0.5  ' 
0.4      ' 

1.5  ' 


A. 


1.  1.2  M.-A. 
0.5      '• 
0.4      " 
1.5       " 


Occurrence  of  the  first 
CaSTe. 


r.  8.0  M.-A. 
4.0       ■' 
6.0       " 
7.0       '■ 


8.0  M.-A. 
4.0      " 
5.5       " 
7.0       " 


518 


SPECIAL  DIAGNOSIS. 


By  studying  these  tables  we  ascertain  from  them  the  relation  be- 
tween these  four  pairs  of  nerves  as  to  the  extent  of  their  irritability, 
and  it  is  possible  to  recognize  with  greater  certainty  a  bilateral  varia- 
tion, especially  of  the  ulnar  or  peronous  nerves. 

{y)  Lastly,  Stintzing  has  given  us  in  a  very  exact  way  the  "  limits 
of  value  "  for  the  irritability  of  nerves  ascertained  in  the  case  of  fifty- 
eight  healthy  persons  (Edelmann's  galvanometer,  normal  electrode  3 
sq.cm.).  But  these  figures  are  only  of  value  for  Stintzing's  normal 
electrode : 


E.  front.  E'.  fae.   .     .     . 

.     0.9—2.0  M.-A. 

N.  ulnaris 

.     0.2—0.9  M 

E.  zygomat.  N.  fac.  . 

.     0.8—2.0       " 

2"  above  the  oleer. 

E.  ment.  N.  fac.  .     .     . 

.     0.5—1.4       " 

N.  radialis 

.     0.9—2.7 

15.  accessorius       .     .     . 

.     0.1—0.44     " 

N.  peroneus     .... 

.     0.2—2.0 

N.  medianus    .     .     .     . 

.     0.3—1.5       " 

N'.  tibialis 

.     0.4—2.5 

In  individual  cases,  however,  Stintzing  has  found  still  smaller  or 
larger  figures.  These  extreme  values  are  exceptions,  possibly,  of  a 
pathological  nature. 

Except  in  the  reaction  of  degeneration,  the  quantitative  irri- 
tability of  the  muscles  very  often  goes  quite  parallel  with  that  of 
the  nerves.  We  can  endeavor  to  determine  this  by  estimating  it. 
Tor  its  relation  to  the  reaction  of  degeneration,  see  under  the  latter 
heading. 

(5)  Qualitative  irritahility  of  muscles  from  galvanic  stimulation. 
Although,  with  respect  to  the  nerves  in  general,  we  are  only  interested 
in  the  strength  of  current  required  to  produce  the  first  occurrence  of 
CaSC  and  CaSTe,  since  the  law  of  contraction  of  the  nerves  is  that 
normally  the  character  is  almost  always  lightning-like,  in  the  direct 
galvanic  stimulation  of  the  muscles,  two  important  variations  come 
into  consideration  :  the  character  of  the  contraction  (whether  lightning- 
like or  slow,  vermifo:cm,  wave-like),  and  further,  the  law  of  contraction, 
and  particularly  the  relation  between  CaSC  and  AnSC.  But  the 
first  point  of  view  is  much  the  more  important. 

There  are  two  classes  of  pathological  galvanic  muscular  reactions : 
1,  the  reaction  of  degeneration  (EaR),  the  exclusive  attribute  of  de- 
generative-atrophic  paralysis  ;  2,  the  myotonic  reaction,  which  occurs 
solely  in  Thomson's  disease. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 


519 


1.    TJie  Reaction  of  Degeneration  {EaB). 

(a)   Complete  JEaR. 

The  electrical  examination  gives  the  following  results : 
Faradic  : 

nerves  :  I  =  0,  that  is,  irritability  (I)  lost, 
muscles  :  I  =  0,  that  is,  irritability  lost. 
Galvanic : 

nerves  :  I  =  0,  that  is,  lost, 
muscles  :  slow,  tonic,  vermiform  contractions  : 
the  quantitative  irritability,  about  normal,  or  increased  or  diminished; 
AnSC  occurs  with  a  less   strong  current  than  the  CaSC,  and  with  a 
less  strength  of  current  from  which  both  take  place,  AnSC  is  greater 
than  CaSC  :  AnSC  >  CaSC. 


{h)  Partial  EaR. 

Faradic : 

nerves  :   diminution  of  I, 
muscles  :  diminution  of  I ; 
Galvanic : 

nerves  :  diminution  of  I, 
muscles :  EaR  as  above. 
For  more  ready  comprehension  we  add  here  two  curves  from  Kast, 
which  graphically  exhibit  the  normal  muscular  reaction  and  the  EaR. 

Fig.  160. 


Diagrammatic  representation  of  the  normal  galvanic  muscular  reaction.  Healthy 
young  girl.  Stimulation  of  the  muscles  in  the  region  of  the  peroneus.  33  cells.  Ka  = 
CaSC;  An  =  AnSC.     (After  Kast.) 


520  SPECIAL  DlAGNOSm. 

Fig.  161. 


Diagrammatic  representation  of  the  reaction  of  degeneration  (EaR).  (After  Kast.) 
Case  of  poliomyelitis  anter.  chronic.  Same  muscles  as  above.  40  cells.  Contractions 
tardy,  AnSC  >  KaSC. 

Course  of  JEaR.  EaE,  is  the  pathognomonic  sign  of  those  changes 
which  take  place  in  muscle,  or  motor  nerves  and  muscle,  when 
they  cease  to  stand  under  the  peculiar  trophic  influence  of  their 
anterior  horn  ganglia — those  alterations  we  designate  as  degenera- 
tion of  the  nerves  and  muscles.  This  degeneration  can  be  most  beau- 
tifully studied  by  the  electrical  phenomena  if  a  nerve  trunk  is,  at 
some  place,  suddenly  interrupted  throughout  its  whole  transverse 
section.  Whenever  there  is  such  an  interruption  there  is  manifest  a 
complete  separation  of  the  portion  of  the  nerve  of  the  muscles  located 
peripherally  from  the  anterior  horn,  which  must  inevitably  lead,  not 
only  to  paralysis,  but  also  degeneration  of  the  portions  cut  off,  and 
with  it  EaR.  But  now  the  case  can  either  proceed  so  far  that  there 
is  a  permanent  interruption  at  the  injured  spot,  which  results  in  com- 
plete atrophy  of  the  nerves  and  muscular  fibres,  or,  after  a  time,  the 
conduction  at  this  place  may  be  restored ;  and  in  the  latter  case  there 
is  a  return  of  the  tissues  of  the  nerves  and  muscles  to  the  normal  con- 
dition— that  is,  there  is  regeneration  of  them.  Now,  according  as  the 
degeneration  of  the  nerve  (muscle)  results  in  atrophy  [i.  e.,  transfor- 
mation into  connective  tissue),  or  again  regenerates  and  returns  to 
its  normal  condition,  the  EaR  shows  a  definite  result  as  such,  and 
also  in  its  temporary  behavior  with  reference  to  the  ability  to  use  the 
muscles.  This  result  of  EaR  may,  of  course,  be  made  use  of  in 
drawing  a  conclusion  as  to  the  condition  of  the  nerves  and  muscles. 

Erb  has  investigated  these  facts  in  regard  to  rheumatic  facial  paral- 
ysis, and  by  experimental  examinations,  in  a  classical  manner.  He 
has  given  representations  for  the  course  of  rheumatic  facial  paralysis, 
which  we  here  insert. 

Fig.  162  gives  a  representation  of  complete  EaR  with  reference  to 
motility,  and  faradic  and  galvanic  irritability  of  the  nerves  and  muscles; 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 


521 


and  over  it  are  given  the  designations  of  the  simultaneous  histological 
changes.  The  line  of  galvanic  muscular  irritability  is  wavy  so  lonfl^  as 
the  qualitative  changes  (slowness  of  contraction  and  preponderance  of 
AnSC)  continued. 

1.  Paralysis  with  relative  early  return  of  motility.  The  first  trace 
of  motility  appears  at  a  time  when  there  is  still  complete  EaR.  One 
week  later  the  faradic  and  galvanic  irritability  of  the  nerves  reappears  ; 


Degeneration 
of  nerves. 

Fig.  162. 
Atrophy,  etc. 
of  muscular  fibres.         Regeneration. 

Cirrhosis 

' 

3. 

' 

1.        2. 

4.        5.         6.        7.        8.        9.        10. 

11.      24,    Weeks. 

Motility 


Complete  EaR  with  reference  to  motion.      Faradic  and  galvanic  stimulation  of  the 
nerves  and  muscles.     Paralysis  with  early  return  of  motility.   (Erb.) 

hence  there  now  is  partial  EaR ;  three  weeks  later,  the  slowness  of 
the  contractions  begins  to  disappear.  Diminished  irritability  of  the 
nerves  and  motility  continues  a  still  longer  time. 

2.    Paralysis   with    later  return  of  motility.      Temporarily    the 
condition  is  like  that  in  Fio:.  162.     Here,   also,   there  is  for  some 


Fig.  163. 
Degeneration  of  Atrophy,  etc., 

nerves.  of  muscles.  Cirrhosis. 


Regeneration. 


1.      2.        5.       6.        10.      15.      20.     25.      30.      35.     40       45.       50.     55.  Weeks, 


Motility 


Paralysis  with  later  return  of  motility.  (Eeb.) 


522 


SPECIAL  DIAGNOSIS. 


time  a  partial  EaR.     All  the  evidences  of  regeneration  return  again 
later. 

3.  Permanent  paralysis.     Motility,  irritability  of  the  nerves,  and 
faradic  muscular  irritability  do  not  return.     The  galvanic  muscular 


Degeneration 
of  nerves. 


Fig.  164. 
Atrophy  ;  nuclear  proliferation  ;  cirrhosis 


Total  atrophy. 


1.        3.       10.       20.       30.       40.      50.       00.      70.       80.     90.       100.     Weeks. 


Motility 


Irremediable  paralysis.  (Erb.) 

irritability  in  the  course  of  some  months  becomes  nil;  the  contractions, 
so  long  as  they  are  still  possible,  are  slow. 


Fir..  165. 


Degenerative  atrophy 
of  muscular  fibres,    r 


Kegeneration. 


9.     Weeks. 


Paralysis  in  which  there  is  only  partial  EaR.  (Erb.) 


4.  Paralysis  in  which  there  is  only  partial  EaR.  The  faradic 
and  galvanic  irritability  of  the  nerves  and  faradic  irritability  di- 
minishes only  to  a  slight  degree.     Motility  returns  again  quite  early. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  523 

Varieties  of  JEaR. 

(a)  Partial  EaR  is  necessarily  accompanied  with  slowness  of  con- 
tractions (which  are  also  indirect — Erb).  Not  only  the  contractions 
which  occur  with  direct  galvanic  irritation  of  the  muscles,  but  all 
contractions,  including  those,  also,  which  occur  with  galvanic  and 
faradic  stimulation  of  the  nerves  and  faradic  stimulation  of  the  mus- 
cles, are  slow  in  their  character.  ["  The  faradic  excitability  of  the 
paralyzed  muscle  undergoes  a  diminution  corresponding  to  that  of 
the  nerve,  but  the  galvanic  excitability  of  the  muscles  manifests  the 
quantitative  and  qualitative  changes  which  are  characteristic  of  the 
severer  forms  of  the  reaction  of  degeneration."] 

(5)  The  AnSC  of  the  nerves  is  slow,  the  CaSC  is  not  (Lowenfeld), 
or,  the  muscle  has  a  slow  faradic  reaction,  while  the  nerve  does  not 
respond  at  all  (Stintzing) ;  or,  the  muscle  has  a  slow,  the  nerve  a 
prompt  faradic  reaction,  etc. 

Stintzing,  with  the  greatest  pains,  has  recently  undertaken  to  bring 
order  out  of  this  confusion  with  remarkable,  although  with  few,  results. 
Probably  it  is  well  to  allow  the  material  to  still  further  accumulate 
before  we  undertake  to  interpret  it,  diagnostically  or  pathologically. 

(e)  Mixed  JElectrieal  Reaction.  We  thus  designate  those  electrical 
reactions  which  occur  when  a  muscle  is  partly  degenerated  and  partly 
normal,  and  a  corresponding  portion  of  the  nerves  is  also  sound 
and  another  portion  degenerated.  Then  we  find  a  diminution,  but 
never  a  loss,  of  faradic  and  galvanic  excitability  of  the  nerves  and 
of  faradic  excitability  of  the  muscles.  But  the  direct  galvanic 
muscular  reaction  causes  the  greatest  difficulties  :  the  contractions 
are  not  exactly  short,  not  altogether  slow,  AnSC=CaSC,  here  and 
there  also  shorter :  it  is  hard  to  discover  its  significance.  All  of  this 
is  not  easy  to  understand,  because  normal  contractions  are  mixed 
with  EaR ;  especially  difficult  is  it,  if,  as  is  almost  always  the  case,  the 
excitability  is  lowered.  The  object  is  sometimes  attained  by  making 
repeated,  indeed,  daily  tests  (when  it  seems  that  EaR  often  becomes 
more  distinct),  by  thorough  examination  of  every  part  of  the  mus- 
cular system  with  weak  as  well  as  with  moderately  strong  currents, 
frequently  changing  the  location  of  the  indifferent  electrode  (which 
must  always  be  done  in  such  a  way  as  to  avoid  exciting  the  nerves).   A 


524  SPECIAL  DIAGNOSIS. 

single  clearer  manifestation  of  EaR  in  one  muscle,  or  in  a  bundle  of 
muscular  fibres,  will  usually  serve  as  an  indication  of  the  whole  disease 
as  degenerative  atrophic  paralysis.  It  is  true  that  EaR  has  twice 
been  found  in  myopathic  muscular  atrophy  in  single  muscles  (Schulte 
and  Zimmerlin).  We  (with  Erb)  do  not  share  the  opinion  of  Wernicke 
that  this  mixture  is  the  single  cause  of  every  case  of  partial  EaR. 

2.  Myotonic  Reaction  (Erb). 

Myotonia  congenita  occurs  in  the  very  powerful  (hypertrophic) 
muscles  which  always  exist  with  this  disease :  they  show  increased 
irritability  and  continuance  of  the  contraction  with  the  faradic  cur- 
rent ;  with  the  galvanic  test,  likewise,  there  is  increased  irritability, 
but  only  contractions  as  the  current  is  closed,  and  then  extremely  slow 
and  continuing  contractions  with  peculiar  formation  of  furrows  and 
depressions.  Stable  acting  currents  (the  stimulating  electrode  placed 
not  upon  the  muscle,  but  on  the  vasti,  for  instance,  near  the  patella) 
produce  rhythmical,  wave-like  contractions  from  the  cathode  toward 
the  anode. 

The  relation  of  EaR  to  the  so-called  mechanical  EaR  is  not  unim- 
portant.    (See,  regarding  this,  on  p.  526.) 

3.  Diagnostic  Value  of  the  JElectrieal  Condition. 

The  reaction  of  degeneration  (EaR)  occurs :  1.  In  all  paralyses 
produced  by  disease  of  the  ganglion  cells  of  the  gray  anterior  columns 
of  the  spinal  cord,  or  of  the  motor  nerves  of  the  bulb.  2.  In  all 
paralyses  produced  by  disease  of  the  anterior  roots  and  of  the  periph- 
eral nerves,  where  the  trophic  influence  of  the  anterior  horn  ganglia 
fails  on  account  of  the  interruption  of  the  conduction,  peripherally, 
in  the  nerve  and  muscle. 

The  reaction  of  degeneration  (EaR),  therefore,  is  closely  connected 
with  degenerative  atrophy  of  the  muscles.  Thus,  it  occurs  :  in  polio- 
myelitis acuta,  chronica,  spinal  progressive  muscular  atrophy,  amyo- 
trophic lateral  sclerosis,  lesions  of  a  section  of  the  gray  anterior  horns 
from  hemorrhage,  tumors,  etc. ;  bulbar  paralysis ;  in  traumatic  lesion 
of  the  peripheral  nerves;  in  neuritis  of  all  kinds;  in  "rheumatic" 
paralyses ;  in  primary  multiple  neuritis  ;  in  toxic  paralyses,  and  those 
that  occur  after  infectious  diseases. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  525, 

The  presence  of  EaR  points  directly  in  opposition  to :  cerebral 
paralysis,  paralysis  from  lesion  of  the  pyramidal  tract  in  the  spinal 
cord ;  further,  against  myopathic  paralysis ;  lastly,  against  functional 
or  hysterical  paralysis. 

Of  course,  the  EaR.  is  to  be  regarded  as  contra-indicating  the 
diseases  last  named,  only  with  the  reservation  that  there  is  no  com- 
plication with  the  conditions  first  named.  Of  this  character  we,  with 
others,  consider  also  the  condition  of  EaR  found  by  Schulte  and 
Zimmerlin  with  myopathic  progressive  muscular  atrophy  [see  previous 
page]. 

In  harmony  with  the  above  principles,  partial  EaR  has  exactly  the 
same  significance  as  complete.  It  occurs  :  1.  In  slight  afiections  (as 
slight  forms  of  rheumatic  facial  paralysis,  slight  paralysis  of  the  arm 
from  pressure).  2.  In  atrophic  paralysis,  which  only  affects  a  portion 
of  the  bundles  of  the  muscular  fibres,  it  is  disseminated  (especially 
frequent  in  spinal  progressive  muscular  atrophy,  amyotrophic  lateral 
sclerosis,  multiple  neuritis),  and,  hence,  as  a  mixed  reaction.  (See 
above,  p.  523.) 

When  EaR  is  absent,  sometimes  it  does  not  strictly  show  that  there 
is  no  affection  of  the  anterior  horns  or  of  the  peripheral  nerves — that 
is  to  say,  it  does  not  do  so  if  we  have  to  do  with  a  disseminated 
disease  (see  Mixed  Reaction).  EaR  may  be  wanting  when  there  is 
an  existing  peripheral  paralysis,  if  it  is  very  slight  (very  slight 
pressure-paralysis  of  the  N.  radialis,  which  heals  in  three  to  four 
weeks). 

EaR  in  muscles  that  are  not  paralyzed  is  seen  by  itself  in  lead- 
paralysis  and  traumatic  paralyses. 

Lessened  excitability,  especially  of  nerves,  without  EaR,  occurs 
chiefly  in  myopathic  muscular  atrophy  (dystrophia  muse,  Erb),  in 
muscular  atrophy  from  disease  of  the  joints,  and  in  lesions  of  the 
spinal  pyramidal  tracts,  especially  if  recent  and  very  severe.  More- 
over, it  is  observed  with  multiple  neuritis.,  arsenic-paralysis,  alcohol- 
paralysis,  bulbar  paralysis,  amyotrophic  lateral  sclerosis,  etc.,  and 
here  it  is  probably  to  be  counted  as  mixed  reaction. 

An  intermitting  general  paralysis  at  intervals  of  one  to  four  weeks, 
which  lasts  for  twenty-four  hours,  with  complete  or  almost  complete 
loss  of  all  electrical  reaction,  has  been  observed  by  Westphal.  Its 
nature  is  very  problematical. 


526  SPECIAL  DIAGNOSIS. 

Increased  excitability  as  manifested  by  early  occurrence  of  CaSC 
and  CaSTe,  occurrence  of  AnOTe,  is  an  extremely  important  sign 
of  tetanus.  Slight  increase  is  observed  in  cerebral,  spinal,  recent 
neuritic  paralyses,  in  progressive  muscular  atrophy  of  spinal  origin 
(here  a  more  considerable  increase,  and  this  in  muscles  that  are  still 
performing  their  function). 

The  increase  of  galvanic  excitability  of  the  muscles  with  EaR,  as 
well  as  of  the  faradic  and  galvanic  irritability  of  the  muscles  with 
myotonic  reaction,  does  not  belong  here.  (For  myotonic  reaction, 
see  above,  p.  524.) 

4.  Mechanical  Exeitahility  of  Muscles  and  Nerves. 

1.  Upon  striking  a  muscle  with  a  percussion-hammer,  we  see  that  a 
short  contraction  occurs,  like  a  CaSC  with  a  tolerably  weak  current. 
We  find  these  contractions  increased  and  usually  quite  decidedly  slow 
in  those  muscles  which  show  electrical  EaR  :  "  mechanical  EaR."  If 
distinctly  present,  this  shows  the  same  thing  as  the  electrical  EaR ; 
but,  often  enough,  it  either  fails  or  is  not  distinct,  while  the  electrical 
examination  proves  the  existence  of  EaR. 

Increased  mechanical  excitability  with  energetic,  but  slowly  de- 
clining and  prolonged  contractions  (to  as  much  as  thirty  seconds,  Erb), 
are  peculiar  to  myotonia  congenita.    [See  p.  524.] 

For  those  who  are  experienced,  mechanical  excitability  is  not  with- 
out its  value  as  a  preliminary  starting-point.  But  it  cannot  be  a 
substitute  for  the  electrical  test. 

2.  Idiomuscular  contractions  are  transverse  prominences  which 
appear  locally  at  the  spot  where  the  muscle  is  struck — thus  far  without 
any  diagnostic  significance. 

3.  Mechanical  excitability  of  the  nerves  (striking  upon  the  trunk 
of  the  nerve  at  the  point  of  electrical  stimulation)  has  individual 
differences.  In  many  healthy  persons  mechanical  irritation  does  not 
cause  any  contraction  at  all.  The  mechanical  excitability  of  the 
nerves — but  not  of  the  muscles — is  very  much  increased  in  tetanus 
(especially  in  the  branches  of  the  N.  facialis). 

4.  Charcot  has  discovered  that  a  peculiar  form  of  over-excitability 
of  the  nerves  and  muscles  is  characteristic  of  the  lethargic  stage  of 
hypnosis  in  very  hysterical  persons:  pressure  upon  the  nerve  or 
muscle  causes  contracture. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  527 

We  mention  here,  further,  the  peculiar  and  obscure  phenomenon  of 
paradoxical  contractions  (Westphal) :  In  passive  dorsal  flexion  of  the 
foot  there  occurs  a  tetanic  contraction  of  the  tibialis  anticus  which 
lasts  from  a  few  seconds  to  several  minutes  ;  the  tendon  of  the  muscle 
becomes  prominent,  the  foot — even  when  it  is  no  longer  held — 
remains  dorsally  flexed.  It  frequently  occurs  in  connection  with 
increased  tendon  reflex. 

5.   Coordination  and  Ataxia. 

In  all  motions  there  is  necessarily  a  more  or  less  complicated 
concurrent  action  of  a  number  of  muscles.  For  example,  in  order 
to  seize  anything  with  the  hand,  not  only  are  a  series  of  muscles 
of  the  arm,  hand,  and  finger  moved,  but  at  the  same  time,  or  a 
minimum  of  time  before,  the  scapula,  as  a  fixed  point  for  the  arm, 
must  be  steadied ;  moreover,  from  the  free  attitude  of  the  body,  the 
shifting  of  the  centre  of  gravity,  brought  about  by  the  motion  of 
the  arm,  must  be  equallized  by  the  contraction  of  the  muscles  of 
the  trunk  and  legs,  and  the  equilibrium  must  be  maintained — a 
proceeding  which,  it  is  evident  from  what  has  just  been  said,  cannot 
be  sharply  defined.  Hence,  in  order  that  the  hand  may  attain  its 
object,  and  in  order  that  it  may  attain  it  in  the  shortest  way  and 
with  a  steady  motion,  a  very  exactly  defined  number  of  muscles 
must  contract  at  the  right  instant  and  with  the  finest  adjustment 
of  energy.  This  correct  selection  of  muscles,  and  their  regula- 
tion as  to  time  and  gradation  of  activity,  is  called  coordination.  It 
is  acquired  by  practice  by  means  of  conscious  and  unconscious  direc- 
tion of  our  motions ;  and  it  is  preserved  by  an  oversight  which  is 
continually  becoming  less  conscious  and  more  unconscious,  and  which 
all  our  motions  acquire. 

Children  at  first  are  ataxic  in  grasping  things  as  well  as  in  walk- 
ing. The  acquired  coordination  in  walking  can  be  partly  lost  again 
from  long-continued  severe  sickness. 

The  processes  for  acquiring  and  for  maintaining  coordination  are 
certainly  very  diversified.  Coordination  will  be  acquired  by  the  cor- 
rections which  will  be  suggested  by  sensible  irritations  of  all  kinds, 
caused  by  the  motions  that  are  made  and  conducted  to  the  central 
organs  :  the  eye  sees,  the  ear  (as  of  the  violinist  and  others)  hears — 
the  motion  itself  or  its  efl"ects,  the  sensibility  of  the  skin,  the  whole 


528  SPECIAL  DIAGNOSIS. 

totality  of  deep  sensibility  furnishes  information — and  the  correc- 
tion depends  upon  the  sense  of  power  of  the  muscles,  which  gives 
unconscious  information  regarding  the  intensity  of  the  work  accom- 
plished each  time  by  the  muscle.  In  this  acquisition  of  coordi- 
nation the  conscious  will  participates  in  many  ways  :  in  maintaining 
coordination  it  recedes  very  extraordinarily,  and  gives  place  to  an 
unconscious  influence  of  the  motions  by  centripetal  influences.  But, 
if  necessary,  it  may  at  any  moment  take  hold,  and  even  with  a  con- 
trary effect  to  that  intended,  in  that  the  unusual,  new  agent  of  the 
regulation  of  the  will  disturbs  the  co5rdination  which  went  on  suc- 
cessfully before  unconsciously.  A  person  says,  "  I  will  make  it  par- 
ticularly beautiful,"  and  just  at  that  instant  he  becomes  awkward. 
This  happens,  not  only  with  nervous  and  embarrassed  people,  but  also 
with  those  who  are  very  calm :  under  the  control  of  the  will,  they 
suddenly  perform  a  motion  which  has  long  been  automatically  made. 
Now  there  is  scarcely  any  doubt  as  to  the  nature  of  the  centripetal 
influences,  but  where  and  how  they  bring  their  influence  to  bear 
upon  the  motor  tract  is  very  far  from  being  clear.  Voluntary 
motions  certainly  proceed  to  a  certain  extent  from  regulation  derived 
from  the  cortex  (where  the  complex  motions,  like  those  for  speech, 
must  exist),  but  certainly  still  other  portions  of  the  brain,  which  prob- 
ably act  as  reflex  centres,  have  an  influence  upon  this  regulation 
(thus  especially  the  cerebellum  for  the  motions  of  the  trunk  and 
legs) ;  and  lastly,  no  doubt  the  gray  anterior  horns  have  a  part  in 
directing  the  continuity  of  motion  :  they  preside  over  the  tonus 
of  the  muscles,  the  antagonizing  tension  constantly  in  action  during 
activity;  they  are  the  seat  of  tendon  ,and  skin  reflexes.  That 
all  these  things  have  an  influence  upon  the  continuity  of  motion 
seems  to  us  (as  well  as  to  many  others)  cannot  be  doubted.  But, 
likewise,  there  is  no  doubt  that  the  various  centripetal  influences  upon 
coordination,  to  a  very  great  extent,  may  act  vicariously  for  one 
another :  when  there  is  the  loss  of  the  conscious  skin  and  muscular 
sensibility,  in  the  disappearance  of  centripetal  stimulation,  they  call 
forth  the  muscular  tonus,  the  more  attentive  regulation  of  the  cor- 
tical innervation  (with  the  assistance,  for  example,  of  the  eyes) 
replaces  the  loss  of  constancy  ;  that,  on  the  other  hand — for  instance, 
in  the  case  of  the  blind — the  exquisite  superficial  and  deep  sensibility 
(conscious  as  well  as  unconscious)  must  become  prominent.    But  now. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  529 

if  coordination  can  no  longer  be  maintained,  then  with  its  disturb- 
ance there  occurs  ataxia.  It  is  clear  from  the  foregoing  that  ataxia 
may  exist  at  the  same  time  with  perfectly  normal  vigor  ;  indeed,  it  has 
nothing  whatever  to  do  with  native  strength. 

Ataxia  shows  itself  according  to  its  degree  only  with  delicate,  or 
it  may  even  with  gross,  functions.  It  usually  occurs  as  an  excess 
of  innervation  in  the  sense  of  directing  motion,  or  as  a  want  of 
restraint  (tabes).:  swing  of  the  legs  in  walking,  putting  the  feet  down 
as  if  stamping,  or  only  a  clumsy  way  of  moving  the  feet  when  turn- 
ing around  (as  in  closing  the  door  of  one's  room)  ;  thus,  on  account  of 
the  uncertainty,  the  legs  are  spread  out  in  standing  and  walking ; 
impossibility  of  describing  a  circle  with  the  foot  when  lying  in  bed, 
inability  to  exactly  place  the  heel  upon  the  knee  of  the  other  leg ; 
when  endeavoring  to  take  hold  of  anything,  the  hand  misses  it,  as  in 
the  effort  to  take  hold  of  one's  own  nose,  in  executing  with  the  hand 
the  finer  movements  of  all  kinds.  In  other  kinds  of  ataxia  there  are 
other  kinds  of  uncertainty,  without  this  character  of  missing  the 
mark,  or  the 'ataxia  of  the  legs  and  trunk  manifests  itself  by  reeling. 
The  control  of  the  eyes  sometimes  diminishes  the  ataxia,  sometimes 
not ;  the  first  is  often  the  case  in  tabes.  Most  ataxic  patients  accord- 
ingly show  a  noticeable  inward  consciousness  with  every  ordinary 
voluntary  motion  (as  walking),  quite  in  contrast  with  persons  in 
health  [see  p.  480]. 

Ataxia  occurs :  {a)  In  cerebral  affections,  and  particularly  those  of 
the  cortex ;  here  with  paresis,  confined  to  a  limb  or  one-half  of  the 
body  ;  with  lesions  of  the  vermiform  process  of  the  cerebellum,  of  the 
crura  cerebelli,  and  of  the  pons  and  the  corpora  quadrigemina ;  and 
lastly,  in  individual  cases  in  ordinary  hemiplegia,  if  there  is  slight 
spasm,  [h)  Especially  in  tabes,  where  ataxia  is  the  most  impor- 
tant symptom,  sometimes  after  disease  involving  the  whole  thickness 
of  the  spinal  cord.  ((?)  Rarely,  and  generally  to  a  slight  degree,  in 
diffuse  peripheral  neuritides.  {d)  Rarely  as  a  highly  developed  dis- 
turbance after  acute  infectious  diseases.  On  the  contrary,  traces  of 
ataxia  after  long  confinement  to  the  bed,  especially  after  acute  dis- 
eases, are  not  at  all  rare.  Co5rdination  is  then  temporarily  and 
only  partly  lost. 

For  details  regarding  the  different  theories  of  ataxia,  especially  those 
in  regard  to  tabes  dorsalis,  see  the  different  special  works.     It  is  our 

34 


530  SPECIAL  DIAGNOSIS. 

opinion  that  only  one  source  of  coordination  has  always  been  assumed, 
in  a  somewhat  one-sided  way,  by  the  advocates  of  the  several  views. 

6.  Spasms  of  the  Voluntary  Muscles. 

We  gather  together  under  this  designation  all  those  pathological 
motions  existing  outside  of  the  influence  of  the  will,  so  we  must  go 
very  much  beyond  the  popular  literal  idea  of  "spasms."  But  this 
cannot  very  well  be  avoided  unless  we  purposely  wish  to  divide  the 
subject  very  minutely.     First,  then,  a  few  general  remarks  : 

Tonic  spasms  are  those  lasting  some  time — from  minutes  to  days 
and  weeks — and  are  symmetrical.  Clonic  spasms  are  contractions  of 
short  duration,  followed  by  relaxation  of  the  affected  muscles.  All, 
with  the  exception  of  some  forms  of  trembling,  are  phenomena  of  irri- 
tation derived  from  the  nervous  system ;  and,  in  fact,  chiefly  from 
the  cortex,  pyramidal  tracts,  the  anterior  horns  of  the  spinal  cord, 
some  probably  also  from  the  peripheral  nerves  (also  from  the  muscles 
themselves :  paralysis  agitans,  contractions  of  fibrillse).  The  patho- 
logical irritation  is  probably  generally  a  direct  one,  but  certainly  also 
partly  reflex ;  and,  indeed,  there  is  no  doubt  that  the  same  kind  of 
spasm  may  be  caused  by  direct  as  well  as  reflex  influences — as  partial 
traumatic  and  reflex  epilepsy.  Many  kinds  of  spasm  consist  of 
motions  that  are  always  similar — many  combined  from  a  few,  and 
sometimes  from  a  great  many. 

Spasms  are  partly  the  intrinsic  element  of  the  given  disease,  the 
thing  of  which  the  disease  consists ;  partly  they  are  a  symptom ;  and 
then  again  they  may  be  a  local  sign,  that  is,  they  may  point  directly 
to  the  seat,  or  point  of  origin,  of  the  disease.  Often  we  must  deter- 
mine other  phenomena  (as  paralysis,  etc.)  for  the  purpose  of  dis- 
covering the  point  of  origin. 

With  certain  spasms,  especially  those  that  are  paroxysmal  and 
general,  the  condition  of  self-consciousness  at  the  time  of  the  attack 
is  of  great  diagnostic  importance.  Also  we  often  have  to  consider  the 
general  mental  condition,  for  many  cases  of  convulsions  lead  us  over 
into  the  territory  of  psychiatria. 

We  now  only  mention  the  diflerent  kinds  of  spasm  : 

Trembling  (tremor)  consists  of  unproductive  motions,  often  only  to 
\>%  seen  by  close  observation,  rapidly  following  one  another.     We 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  531 

recognize  them  partly  by  observing  the  limb  when  at  rest,  partly 
when  the  hand  is  stretched  out,  or  is  holding  a  glass  of  water,  and  also 
by  the  handwriting. 

Graphic  representation  shows  that  the  different  forms  of  tremor  differ 
in  the  form,  frequency,  and  rhythm  of  the  contractions.  Trembling 
is  physiological  with  bodily  exertion,  and  with  mental  excitement,  and 
it  is  sometimes  constant,  even  with  persons  in  good  health.  Upon 
the  borders  of  the  normal  stand  the  tremors  of  the  aged,  tremor  senilis. 
Alcoholic  tremor,  especially  of  the  extremities  and  tongue,  occurs 
with  the  passing  away  of  the  effects  of  the  indulgence,  or  when  it  is 
declining;  the  tremor  saturninus,  the  tremor  which  affects  morphia- 
habitues  when  they  abstain  from  it,  that  with  morbus  Basedoivii 
(generally  very  fine,  rapid  movements,  sometimes  also  coarser  con- 
tractions), and  the  tremors  of  nervous  individuals,  are  the  finer  kinds 
of  tremors. 

The  tremor  of  paralysis  agitans  (especially  of  the  extremities,  but 
also  of  the  head)  manifests  itself  by  a  symmetrical  rhythm,  by  a  very 
characteristic  position  of  the  hand  and  fingers  ("  pill-maker  ").  It 
ceases  when  voluntary  motions  are  made,  especially  if  vigorous,  but 
sometimes  even  when  writing. 

On  the  other  hand,  the  intention  tremor  occurs  only  with  voluntary 
motions,  in  that  toward  the  end  of  the  motion  it  becomes  stronger ;  it 
stops  as  soon  as  the  patient  is  quiet.  It  is  an  important  symptom  of 
multiple  sclerosis ;  it  occurs,  however,  as  tremor  mercurialis.  In  many 
cases  it  is  difficult  to  distinguish  it  from  ataxia  (which  see). 

Between  "tremor"  and  "clonic  spasms  "  it  is  not  possible  to  draw 
a  precise  distinction.  The  designation  shaking-spasm  is  used  for  the 
transition  forms  of  both.  The  prominent  transition  forms  of  this  kind 
of  tremor  are  those  shiverings  which  begin  with  fine  tremors,  becoming 
constantly  coarser  with  cooling  off,  and  with  rapidly-rising  fever ; 
with  hysteria  there  are  conditions  that  resemble  tremor.  Likewise  is 
to  be  mentioned  the  quaking  which  occurs  with  marked  active  spasm 
of  the  legs,  as  especially  takes  place  sometimes  after  mechanical  irri- 
tation ;  foot  clonus,  particularly,  often  shows  these  transition  forms 
very  beautifully. 

In  the  foregoing  we  have  not  distinguished  between  the  tremors  of 
spasm  and  those  of  paralysis,  because  in  regard  to  most  kinds  of 
tremors  it  is  not  yet  clear  to  which  of  the  two  classes  they  belong. 


532  SPECIAL  DIAGNOSIS. 

For  further  points    regarding  this   subject,  see  the  several  special 
works. 

Fibrillary  contractions  are  contractions  in  individual  coarse  or  fine 
bundles  of  muscular  fibres  which  do  not  produce  motion  in  the  limb. 
In  individual  cases,  however,  we  can  observe  a  very  diminutive  motor 
effect.  They  are  easily  recognized  by  observing  the  muscle.  In 
health  they  are  often  excited  (with  great  individual  differences)  by  the 
cooling  of  the  skin ;  but  they  also  occur  with  atrophic  paralysis,  and 
very  abundantly,  and  hence  are  not  without  diagnostic  value,  in 
spinal,  progressive  muscular  atrophy. 

Clonic  spasms  rarely  occur  by  themselves,  but  they  more  frequently 
accompany  epileptic  and  other  attacks  of  convulsions  (see  below).  We 
sometimes  observe  them  isolated  in  local  affections  of  the  cortex  of  the 
brain  (see  below,  Partial  Epilepsy) ;  but  also  in  other  localized  cerebral 
diseases,  and  in  myelitis  transversa,  as  single  brusque  bending  motions 
of  the  legs,  generally  both  legs  together — probably  of  reflex  origin. 

Tonic  spasms,  by  themselves,  occur  most  frequently  in  the  form  of 
active  spasms  (see  above,  p.  494),  in  lesions  of  the  pyramidal  tracts, 
and  with  hysteria.  Moreover,  they  occur  in  tetanus,  and  in  these  forms : 
as  masseter  spasms  in  trismus  ;  this  latter  also  by  itself;  as  rigidity  of 
the  face,  risus  sardonicus  ;  extension  of  the  vertebrae  with  rigidity  of 
the  neck  and  opisthotonus,  and  in  spasms  of  the  legs  in  the  state  of 
extension.  Moreover,  tonic  spasm  of  the  muscles  occurs  when  first 
moving  them  after  long  rest,  and  as  a  prolonged  condition  after 
voluntary  contractions  in  myotonia  congenita;  also,  occasionally, as 
bending  and  adduction  spasms  of  the  arm  and  hands  in  tetanus ;  as 
the  tonic  form  of  writers'  cramp,  although  seldom  purely  as  such, 
generally  with  slight  contractions  mixed  with  tremor ;  and  in  the  first 
stage  of  epileptic  attacks  (see  below). 

Epileptic  spasms,  in  genuine  epilepsy,  generally  pursue  a  typical 
course :  after  certain  subjective  warnings  (aura),  or  without  these,  there 
is  a  sudden  loss  of  consciousness,  ushered  in  with  a  cry,  and  imme- 
diately the  patient  falls  down.  Then  there  is  a  short  tonic  spasm  of 
all  of  the  voluntary  muscles  (more  especially  of  the  extensors  of  the 
arms,  legs,  vertebrae,  but  the  hands  are  closed  and  the  thumb  is  grasped 
by  the  fingers) ;  then  there  is  clonic  spasm,  with  frightful  vigor,  of 
all  the  muscles  of  the  body,  including  the  muscles  of  the  eyes, 
tongue,  etc. ;  after  a  few  minutes  there  follows,  either  gradually  or 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  533 

suddenly,  a  period  of  relaxation  with  continued  loss  of  consciousness 
— post-epileptic  coma.  During  the  attack,  the  tongue  is  often  bitten, 
involuntary  discharges  take  place,  and,  from  the  interference  with 
respiration,  marked  cyanosis  often  occurs. 

It  is  very  important  to  make  a  differential  diagnosis  between  genuine 
epilepsy  and  symptomatic,  which  often  very  much  resembles  the 
■former.  Tiie  latter  occurs  in  all  manner  of  anatomical  diseases  of  the 
brain  (regarding  partial  epilepsy  in  disease  of  the  cortex  of  the  brain, 
see  below),  as  traumatic  and  reflex  epilepsy,  as  epileptiform  spasms  in 
uraemia,  these  latter  also  as  eclampsia  gravidarum. 

There  occur  in  children,  upon  slight  provocation,  epileptiform  or 
eclamptic  attacks  during  dentition,  from  intestinal  irritation  from 
worms,  in  the  beginning  of  acute  infectious  diseases,  as  scarlet  fever, 
measles,  pneumonia,  and  in  the  beginning  stage  of  acute  poliomyelitis 
and  encephalitis. 

It  is  generally  very  difficult  to  form  an  opinion  regarding  spasms 
from  the  anamnesis.  Here  we  must  be  very  cautious  in  arriving  at  a 
diagnosis. 

Partial  epilepsy  (Jackson's  or  cortical).  In  this  there  are  epilepti- 
form convulsions  which  are  limited  to  an  extremity  or  to  the  facial  mus- 
cles of  one  side.  They  are  an  almost  infallible  sign  of  disease  located  in 
a  corresponding  part  of  the  cortex  of  the  brain,  and  also  are  connected 
with  or  followed  by  paresis,  increased  tendon  reflex,  and  sometimes  by 
disturbance  of  the  sensibility  of  the  affected  limb  (monoplegia).  The 
convulsions  may  be  unilateral  or  even  general,  but  they  manifest 
themselves  as  originally  partial  epileptic,  by  beginning  in  the  affected 
limb. 

Hysterical  convulsions  (attacks  of  hystero-epilepsy)  sometimes  have 
a  great  likeness  to  epilepsy ;  yet  almost  always  the  motions  may  be 
distinguished  in  that  they  are  more  wide-reaching  [and  tumultuous], 
and  more  than  all  by  the  fact  that  they  partly  manifest  coordinated 
motions,  or  remind  one  of  them.  Motions  such  as  we  see  made  by  a 
person  senselessly  furious,  or  an  unruly  child,  are  not  at  all  infre- 
quent ;  especial  manifestations  are  flits  of  laughing,  shouting,  weeping, 
coughing. 

Tbe  most  important  mark  of  difference  between  hysterical  and 
epileptic  spasms,  in  doubtful  cases,  is  that  in  the  former  there  is  almost 
never  an  entire  loss  of  consciousness ;  very  often  it  remains  quite 


534  SPECIAL  DIAGNOSIS. 

intact;  and  the  absence  of  involuntary  discharges  (urine,  stool,  in 
males  also  of  semen),  as  is  not  infrequent  with  genuine  epilepsy ; 
lastly,  the  tongue  is  not  bitten,  and  there  is  reaction  of  the  pupil 
during  the  attack. 

G-ross  [severe]  hysteria.  The  attack  of  hystero-epilepsy  may  pass 
into  a  second  stage  ["phase  des  grand  mouvements  "  of  the  French] 
of  contortions,  and  excessive  movements — among  others,  especially' 
that  of  the  "arc  de  cercle  "  (head  bent  backward,  boring  into  the 
pillow;  the  trunk  bent  as  in  opisthotonus) — -which  may  last  for  hours, 
are  characteristic  manifestations  ;  then  there  may  follow  a  third  stage, 
which  is  either  quiet  or  may  be  excited  (delirium) — tho  stage  of  hal- 
lucinations and  of  emotional  attitudes.     The  stages  may  occur  singly. 

Besides  what  has  already  been  described,  it  is  important  for  diag- 
nosis that  there  should  be  present  hysterical  signs  (stigmates  hys- 
t^riques),  manifested  by  the  patient  in  the  form  of  sensory  anaesthesia, 
especially  a  concentric  limitation  of  the  field  of  vision ;  also,  hemi- 
ansesthesia;  hysterogenous  zones — that  is,  hypersesthetic  regions  of 
the  body  (ovaries,  testicles,  circumscribed  portions  of  the  skin),  the 
irritation  of  which  by  pressure  sometimes  causes  an  attack  or  is  asso- 
ciated with  one. 

Constrained  positions  and  motions,  ^o  the  former  belong  the 
drawing  of  the  head  or  trunk  to  one  side,  so  that  the  patient  assumes 
the  side  position  in  bed  (sometimes  with  the  eyes  fixed:  deviation 
conjugee  occurs  with  the  other  manifestations);  to  the  latter  belong 
the  involuntary  forward,  backward,  and  movement  in  a  circle 
(manegegang).  Both  phenomena  indicate  a  lesion  of  the  vermiform 
process  ot  the  cerebellum  or  of  the  median  crus  cerebri. 

With  the  constrained  motions,  or  the  "  coordinated  spasms,"  are 
also  to  be  reckoned  the  gross  motions  previously  mentioned  under 
hysteria,  as  laughing,  screaming,  etc. 

Chorea  minor.  This  is  the  designation  given  to  the  very  rapid, 
lightning-like,  entirely  irregular  muscular  contractions,  which,  on  the 
one  hand,  produce  restlessness  of  the  limbs  and  of  the  face ;  and,  on 
the  other,  disturb  and  divert  the  regular  voluntary  motions.  They 
afiect  the  head  (face,  tongue,  masticating  muscles)  of  the  trunk,  espe- 
cially of  the  shoulders  and  legs,  and  sometimes  the  glottis.  They 
occur  in  all  degrees  of  severity,  from  single  weak  jerks  to  the  most 
extravagantly  confused  strong  movements  (folie  musculaire).     If  the 


EXAMINATION  OF  THE  NERVOUS  SYSTEM  535 

subject  is  embarrassed,  especially  if  observed,  frequently  the  contrac- 
tions are  increased.  During  sleep  (but  there  may  be  difficulty  in 
getting  to  sleep),  the  convulsions  entirely  disappear,  excepting  in  par- 
ticularly severe  cases. 

Chorea  minor  is  not  often  purely  one-sided,  or  hemichorea.  Hemi- 
chorea  may  occur  either  as  the  forerunner  or  as  the  result  of  hemi- 
plegia, when  it  indicates  a  lesion  of  the  posterior  section  of  the  inner 
capsule  or  of  the  optic  thalamus.  Especially  frequent  are  choreic  or 
athetose  motions  (which  see),  with  declining  acute  encephalitis  in 
children  (poliencephalitis,  Striimpell)  in  the  paralyzed  limbs.  Quite 
recently,  Flechsig  has  found  both  internal  segments  of  the  lenticular 
nucleus  diseased  in  several  cases  of  severe  general  chorea  with 
delirium. 

Athetosis  [described  by  W.  A.  Hammond].  This  designates  pecu- 
liar, slow,  and  at  the  same  time  tolerably  energetic  motions,  particu- 
larly of  the  hands,  arms,  shoulders,  but  also  anywhere  else.  If  the 
motions  are  somewhat  quicker  than,  but  resembling,  those  of  chorea, 
they  then  form  a  transition  to  the  latter.  Athetosis,  as  well  as  chorea, 
is  a  disease  in  itself;  hemiathetosis  is  observed  in  the  same  cerebral 
locations  as  hemichorea  (which  see).  In  the  cerebral  paralyses  of 
children  it  is  more  frequent  than  hemichorea. 

Associated  movements  are  abnormal  involuntary  motions,  which 
take  place  with  the  performance  of  voluntary  motions  by  the  contrac- 
tions of  muscles  in  regions  which  have  nothino-  to  do  with  the  motions 
desired.  We  find  them  especially  in  cerebral,  but  also  in  spinal,  and 
even  in  peripheral,  paralyses ;  hence  they  cannot  be  made  use  of 
as  an  aid  in  diagnosis.  Sometimes  we  see  them  in  muscles  of  the 
same  limb  as  that  put  in  motion.  Particularly  frequent  is  a  dorsal 
flexion  of  the  foot  when  the  leg  is  drawn  up  to  the  abdomen,  as  in 
hemiplegia,  spastic  spinal  paralysis  (Striimpell),  or  in  unilateral 
affections,  as  synonymous  associated  movements  of  the  sound  side 
with  those  of  the  diseased  side,  or  of  the  diseased  side  with  the  sound 
side. 

Catalepsy,  cataleptic  rigidity,  fiexibilitas  cerea,  is  a  peculiar  in- 
crease of  the  tonus  of  the  voluntary  muscles,  of  such  a  character  that 
the  limbs  not  only  off"er  only  a  very  slight  or  feeble  resistance  in 
passive  motion,  but  also  remain  in  a  given  position,  even  when  it  is 
opposed  to  gravity,  and  this  sometimes  for  an  hour  and  more  at  a 


536  SPECIAL  DIAGNOSIS. 

time.  Catalepsy  very  rarely  occurs  in  anatomical  diseases,  as  tumors 
of  the  brain  and  meningitis ;  more  frequently  in  hysteria,  especially 
in  hypnosis,  and  in  certain  psychoses,  as  in  melancholia  attonita. 

7.    Voluntary  Muscles,  their  Innervation,  their  Function,  and  the 
Diseases  that  Disturb  Them. 

1.  Muscles  of  the  eye  (see  Examination  of  the  Eye). 

2.  Muscles  of  the  face,  supplied  by  the  N.  facialis  : 

M,  frontalis  draws  up  the  brow  and  causes  wrinkles  across  the 
forehead. 

M.  corrugator  supercil.  draws  the  skin  of  the  forehead  over  the 
roots  of  the  nose  into  folds. 

M.  orbicularis  palpebrarum  closes  the  eyes. 

M.  depressor  nasi  seu  dilator  narium  dilates  the  nostrils. 

M.  levator  lab.  super,  (propr.)  and  M.  levator  anguli  oris  lift  up 
the  upper  lip  and  the  corner  of  the  mouth. 

M.  zygomaticus  major  raises  up  and  draws  out  the  angle  of  the 
mouth. 

M.  buccinator  makes  the  cheeks  tense,  holds  open  the  pouch  of  the 
cheek  when  eating,  prevents  the  distention  of  the  cheeks  when  blowing 
or  when  whistling  (to  a  slight  extent  supplied  by  the  trigeminus  ?). 

M.  orbicularis  closes  the  mouth ;  is  the  chief  factor  in  whistling, 
pronouncing  the  consonants  b,  f,  m,  p,  v,  w,  the  vowels  o,  u  (greatly 
assisted  by  the  levator  menti). 

Paralysis  of  the  facial:  The  forehead  is  smooth  and  remains  so  upon 
the  affected  side  when  the  effort  is  made  to  wrinkle  it ;  the  eye  remains 
open  and  cannot  be  closed  (lagophthalmus) ;  the  naso-labial  furrow  is 
obliterated ;  the  angle  of  the  mouth  hangs  down ;  the  mouth,  and 
often  also  the  tip  of  the  nose,  are  drawn  toward  the  sound  side ;  the 
effort  to  expose  the  teeth,  as  in  cleansing  the  teeth,  makes  very 
plain  the  defective  elevation  of  the  upper  lip  and  distortion  of  the 
mouth.  When  blowing,  the  affected  cheek  is  distended ;  on  attemptr 
ing  to  whistle,  the  lips  are  drawn  to  the  sound  side ;  if  the  paralysis 
is  unilateral,  the  labials  are  generally,  except  in  recent  paralyses,  pro- 
nounced distinctly ;  if  bilateral,  they  cannot  be.  (See  further.  Soft 
Palate,  Hearing,  Taste.) 

3.  Muscles  of  mastication,  tongue,  soft  palate,  pharynx.  Mm. 
temporalis  and  masseter  (N.  trigeminus  branch  III.)  draw  up  the  lower 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  537 

jaw  and  press  the  teeth  together.  Mm.  pterygoidei  eifect  the  side- 
ways movement  (rotation)  of  the  lower  jaw. 

Paralysis  of  these  muscles  will  be  recognized  by  the  absence,  upon 
one  or  both  sides,  of  these  motions;  bilateral  paralysis  of  the  temporalis 
and  masseter,  by  the  dropping  down  of  the  lower  jaw.  Palpation 
below  the  zygoma  detects  possible  paralysis  arid  atrophy  of  the  mas- 
seter ;  above  the  zygoma,  paralysis  and  atrophy  of  the  temporalis  by 
its  laxity. 

We  pass  over  the  complicated  arrangement  of  muscles  which  draw 
down  the  lower  jaw,  because  their  paralyses  have  not  yet  been  suffi- 
ciently studied. 

The  tongue  is  stretched  out — that  is,  it  is  drawn  forward  by  the 
two  Mm.  geniohyoglossi,  which  act  somewhat  convergently,  and  is 
•drawn  back  chiefly  by  the  two  Mm.  styloglossi ;  M.  hypoglossus 
principally  draws  it  down.  These,  and  the  inner  lingual  muscles, 
produce  the  changes  in  the  form  of  the  tongue. 

Unilateral  hypoglossal  j^aralysis  :  When  the  tongue  is  protruded  it 
deviates  toward  the  paralyzed  side,  because  the  genioglossus  of  the 
sound  side  pushes  it  that  way.  Bilateral  paralysis  (generally  atrophic) 
causes  diminution  of  all  the  motions,  even  to  their  complete  oblitera- 
tion ;  difiiculty  in  mastication  and  swallowing ;  and  in  the  formation 
•of  the  consonants  c,  d,  g,  k,  1,  n,  r,  s,  sch,  x,  z,  and  of  the  vowels  i 
[e],  e  [a].  Unilateral  paralysis  produces  all  these  disturbances  to  a 
slight  degree,  and  they  become  less  with  habit.  Atrophy,  seldom 
unilateral,  will  be  recognized  by  diminution  in  the  volume,  by 
wrinkles,  and  sensible  thinness. 

The  soft  -palate  derives  its  principal  innervation  from  the  spheno- 
palatine ganglion  (N  petrosus  superfic.  maj.,  and  from  the  ganglion 
geniculi  of  the  facial  nerve.  The  fifth  and  the  tenth  and  eleventh 
ganglia  also  take  part). 

Examination:  by  inspection  and  phonation — i.  e.,  by  observing  the 
voice  and  inspection,  and  by  the  swallowing  of  fluids. 

Unilateral  paralysis  of  the  soft  palate  in  paralysis  of  the  facial 
located  high  up,  shows  deviation  of  the  uvula  toward  the  healthy  side 
and  depression  of  the  arch  of  the  paralyzed  soft  palate,  both  more 
distinctly  in  phonation.  In  the  passive  state,  the  relaxed  uvula  may 
hang  to  one  side,  even  when  there  is  no  paralysis.  Sometimes  the 
speech  is  nasal,  and  fluids  may  escape  from  the  nose  in  attempting  to 


538  SPECIAL  DIAGNOSIS. 

swallow.  Both  symptoms  are  due  to  ineiFectual  closure  between  the 
nose  and  the  mouth :  pharyngeal  space.  In  bilateral  paralysis,  espe- 
cially with  bulbar  paralysis  and  as  diphtheritic  paralysis,  the  soft 
palate  hangs  down  without  any  power  to  contract ;  and  nasal  utter- 
ance and  the  difficulty  in  swallowing  are  increased. 

The  'pliaryngeal  muscles  (N.  X.-XI.),  with  the  aid  of  the  tongue, 
accomplish  the  act  of  swallowing.  When  they  are  palsied,  this  act 
is  disturbed,  and,  from  the  lack  of  vigor  and  promptness  in  passing 
the  food  along,  it  easily  enters  the  larynx  :  thus,  there  is  coughing  in 
connection  with  swallowing.  But  if  the  patient  is  unconscious,  or 
there  is  at  the  same  time  disturbance  of  the  sensibility  of  the  larynx 
(N.  laryngeus  super,  vagi),  there  may  be  no  cough. 

4.  Laryngeal  muscles.  The  muscles  supplied  by  the  laryngeus 
super,  vagi  are :  depressors  of  the  epiglottis ;  Mm.  thyreoepiglott., 
aryepiglottici  (paralysis  :  difficulty  in  swallowing),  and  the  M.  crico- 
thyreoides,  tensors  of  the  vocal  cords  by  movement  of  the  thyroid 
cartilage  toward  the  cricoid  cartilage  (paralysis :  hoarse  voice). 

N.  laryngeus  inferior  (recurrent  branch  of  the  N.  X.-XI.) :  Mm. 
crico  arytsenoid.  postici  dilate  the  glottis  (bilateral  paralysis:  inspi- 
ratory dyspnoea,  sometimes  of  the  severest  kind,  with  the  voice 
unchanged  or  very  slightly  impure).  Mm.  thyreo-arytsenoidei  are 
the  most  important  tensors  of  the  vocal  cords  (paralysis :  loss  of  voice 
»and  hoarseness). 

Musculi  arytaenoidei  transversi  et  laterales :  they  narrow  the  pos- 
terior portion  of  the  glottis  (in  isolated  paralysis :  the  voice  is  very 
hoarse,  as  in  catarrh,  hysteria).  Mm.  crico-arytsenoidei  laterales  :  in 
connection  with  the  preceding  they  narrow  the  glottis. 

Complete  paralysis  of  the  recurrent :  [a)  unilateral  (compression  by 
aortic  aneurism,  carcinoma  of  the  oesophagus,  mediastinal  tumors ; 
bulbar  paralysis) :  voice  hoarse,  easily  changing  to  the  falsetto,  or 
little  or  even  not  at  all  altered  ;  (h)  bilateral  (rare) :  complete  aphonia, 
inability  to  cough. 

(Regarding  the  laryngoscopic  examination,  see  Appendix.) 

5.  Muscles  of  the  throat  and  neck.  M.  sterno-cleido-mastoideus 
(N.  XI.)  draws  the  head  and  face  toward  the  opposite  side  and  looking 
upward ;  both  together  somewhat  bend  the  neck  and  push  the  head 
forward :  or,  if  the  head  is  the  fixed  point,  they  lift  up  the  sternum 
or  the  clavicles,  as  in  emphysema.     The  test  of  their  function  and 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  539 

recognition  of  their  paralysis  and  spasm  is  easy.  When  both  are 
paralyzed,  the  neck,  and  with  it  the  head,  incline  backward. 

The  muscles  that  stretch,  bend,  twist  the  neck  or  the  head  (nervi 
cervical.  I.-IV.),  maintain  the  head  in  the  upright  position.  If  they 
are  weak  or  paralyzed,  it  is  impossible  to  hold  the  head  up :  it  falls 
forward,  if  it  is  not  exactly  balanced.  This  happens,  if  the  head  is 
too  heavy  (hydrocephalus).  Defective  mobility  of  the  head  is  more 
frequently  caused  by  spasm  or  inflammation  (stiff-neck,  caries  of  the 
cervical  vertebrae),  than  by  paralysis. 

6.  Muscles  of  the  trunk.  Muscles  that  move  the  vertebrae  (inner- 
vated by  Nn.  dorsales  and  lumbales). 

Lumbar  extensors  and  extensors  of  the  lower  vertebrae :  M.  erector 
trunci  (sacro-lumb.  et  longissim.)  with  bilateral  action. 

Bending  forward  :   the  abdominal  muscles. 

Bending  of  the  lower  vertebrae  sideways  :  quadrati  lumborum. 

Twisting  the  trunk  :  semispinalis  and  multifidus. 

Paralysis  of  the  erector  trunci :  (a)  bilateral :  the  body  is  bent 
backward  (lordosis  of  the  lumbar,  kyphosis  of  the  upper  thoracic, 
vertebrae,  in  such  a  way  that  the  latter  overhangs  the  sacrum ;  a 
plumb-line  held  from  it  falls  behind  the  sacrum) ;  the  pelvis  is  tilted 
up,  the  knees  are  bent,  (h)  Unilateral :  in  standing,  a  scoliosis  of 
the  lower  vertebrae  is  convex  toward  the  diseased  side ;  on  the  other 
hand,  there  is  a  compensatory  scoliosis  of  the  thoracic  vertebrae. 

Paralysis  of  the  abdominal  muscles  :  marked  lordosis  of  tte  lumbar 
and  lower  thoracic  vertebrae,  compensatory  kyphosis  of  the  upper 
thoracic  vertebrae,  but  these  are  exactly  vertical  over  the  sacrum. 
There  is  marked  inclination  of  the  pelvis. 

In  paralysis  of  the  extensors,  it  is  impossible  to  place  the  bent 
trunk  in  an  unsupported  upright  position ;  it  is  accomplished  by 
placing  the  hands  upon  the  knees  and  thighs.  If,  in  addition,  there 
is  paralysis  of  the  glutei,  especially  of  the  gluteus  maximus,  then  the 
patient  can  only  rise  from  the  floor  by  first  getting  down  on  "  all 
fours,"  then  pushing  himself  up  with  the  hands  from  the  floor,  in  order 
immediately  to  put  them  upon  the  knees  and  thus  further  support  the 
body:  this  is  his  way  of  standing  up.  In  paralysis  of  the  flexors,  it 
is  impossible  to  sit  up  from  the  dorsal  position  without  assistance. 

Opistliotonus  is  produced  by  spasm  of  the  extensors,  emprosthotonus 


540  SPECIAL  DIAGNOSIS. 

by  spasm  of  the  flexors ;  unilateral  spasm  of  the  extensors  causes 
scoliosis,  convex  toward  the  diseased  side. 

7.  Muscles  of  the  thorax.,  diaphragm^  and  abdomen.  Here  belongs 
most  of  what  has  already  been  said  upon  p.  81fF.  There  we  learn 
regarding  the  ordinary  and  the  auxiliary  muscles  of  inspiration  and 
the  auxiliary  muscles  of  expiration. 

Paralysis  of  the  diaphragm  (phrenic  nerve,  chiefly  from  the  fourth 
nerve  of  the.  [deep]  cervical  plexus)  in  perfect  quiet,  may  be  entirely 
compensated  by  the  thoracic  muscles  of  inspiration  ;  but  otherwise  every 
increased  requirement  for  breath  produces  marked  dyspnoea ;  and  this 
is  exactly  the  case  with,  respect  to  the  vicarious  action  of  the  dia- 
phragm when  there  is  defective  thoracic  breathing.  It  will  be  under- 
stood, then,  that  paralysis  of  the  auxiliary  muscles  of  respiration  has 
only  a  bad  outlook  for  the  breathing  when  it  comes  to  such  a  pass  that 
they  must  be  called  upon  (see  p.  96). 

Tonic  and  clonic  spasm  of  the  thoracic  muscles  of  inspiration  in 
tetanus  and  epilepsy  at  once  cause  severe  cyanosis;  in  the  first  disease 
it  may  be  fatal ;  also  tonic  spasm  of  the  diaphragm  interferes  very 
much  with  breathing  and  may  be  dangerous  to  life.  Clonic  spasm  of 
the  diaphragm  (singultus,  hiccough),  in  a  mild  form,  is  not  infre- 
quently seen ;  if  it  continues  for  hours  and  days,  as  it  sometimes  does 
in  abdominal  and  cerebral  afi'ections,  then  from  the  disturbance  of  the 
rest,  and  severe  pain  along  the  line  of  insertion  of  the  diaphragm,  it 
may  bring  about  a  serious  condition. 

By  the  contraction  of  the  abdominal  muscles  the  anterior  abdominal 
wall  is  flattened,  and  thus  the  abdominal  cavity  is  lessened ;  by  the 
simultaneous  contraction  of  the  diaphragm  there  arises  "  the  abdominal 
pressure,"  which  is  important  in  defecation  and  emptying  the  bladder, 
and  the  expulsion  of  the  child  in  labor.  The  role  of  the  rectus  and 
obliquus  externus,  as  flexors  of  the  vertebral  column  (when  those  of 
one  side  act  alone,  the  trunk  is  bent  laterally  forward  over  on  one  side), 
has  been  already  mentioned,  as  v/ell  as  their  function  in  active  expi- 
ration. 

8.  Muscles  of  the  upper  extremity. 

(a)  Muscles  which  move  the  shoulder-blade  or  fix  it :  M.  trapezius 
(N.  accessorius  for  the  most  part)  rajses  the  shoulder-blades  and  draws 
them  toward  the  middle  line,  both  of  these  by  the  middle  and  posterior 
par.ts.     The  former  chiefly  lifts  up  the  acromion,  the  latter  the  inner 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  541 

upper  angle.  With  its  anterior  clavicular  portion  it  inclines  the  head 
obliquely  backward  and  at  the  same  time  lifts  up  the  acromion.  Paral- 
ysis of  the  trapezius  permits  the  scapula  to  drop  down,  to  be  drawn 
away  from  the  middle  line,  and  at  the  same  time  to  turn  round  so  that 
its  apex  moves  toward  the  spinal  column  (because  the  levator  scapulae 
holds  up  the  upper  inner  angle).  The  shoulder  sinks  downward  and 
forward ;  there  is  diflficulty  in  raising  the  upper  arm,  because  the 
scapula  is  not  so  perfectly  fixed,  and  shrugging  of  the  shoulders  is 
restricted.     From  what  has  been  said  the  test  of  its  function  is  easy. 

M.  levator  anguli  scapulae  (N.  dorsalis  scapulae  from  the  cervical 
plexus)  lifts  up  the  scapula  by  its  inner  upper  border,  with  the  ten- 
dency to  turn  the  right  scapula  in  the  direction  of  the  hands  of  the 
clock,  and  the  left  in  the  opposite  direction.  Its  paralysis  can  only 
be  recognized  when  the  trapezius  is  paralyzed  at  the  same  time,  by 
the  complete  inability  to  lift  the  shoulder. 

Mm.  rhomboideus  major  et  minor  (N.  dorsalis  scapulae)  draw  the 
shoulder-blades  toward  the  spinal  column,  and  thus  lift  them  in  the 
same  way  as  t^e  levator  scapulae  and  turn  them  in  such  a  way  that 
the  lower  angle  of  the  scapula  is  nearest  the  spinal  column.  They 
fix  the  scapulae,  especially  in  backward  motions  of  the  arms  and  legs, 
and  when  lifting  weights.  Paralysis  [of  these  muscles]  moves  the 
scapula,  and  particularly  its  lower  angle,  away  from  the  spinal  column. 
Moreover,  it  is  difficult  to  detect  paralysis  of  these  muscles  when  the 
trapezii  are  normal. 

M.  serratus  anticus  (N.  thoracicus  longus  seu  posterior,  Henle,  from 
the  brachial  plexus)  turns  the  scapula  in  such  a  way  that  the  lower 
angle  moves  outward,  draws  it  somewhat  away  from  the  spinal  column, 
and  presses  it  against  the  thorax :  it  is  an  important  fixation-muscle 
of  the  scapula  when  the  arms  are  lifted.  When  the  scapula  is  fixed 
(by  the  rhomboidei)  it  is  a  muscle  of  inspiration.  Paralysis  of  the 
serratus,  in  the  condition  of  rest,  causes  a  slight  elevation  and  rotation 
of  the  scapula,  so  that  the  lower  angle  stands  out  a  little  from  the 
thorax  and  is  (slightly)  drawn  toward  the  spinal  column.  The  arm 
can  be  lifted  up  to  the  horizontal  sideways :  this  moves  the  inner  border 
of  the  scapula  close  up  to  the  vertebral  column.  It  can  only  be  raised 
higher  by  fixing  the  scapula  in  the  same  way  as  would  be  accomplished 
by  the  serratus.  When  the  arm  is  moved  forward,  the  inner  border  of 
the  scapula  stands  out  like  a  wing. 


542  SPECIAL  DIAGNOSIS. 

(b)  Muscles  of  the  trunk  and  of  the  scapula  [attached]  to  the  upper 
arm  : 

M.  deltoides  (N.  axillaris  at  the  infraclavicular  portion  of  the 
brachial  plexus) ;  the  middle  portion  extends  the  arm  outward  from  the 
body,  the  anterior  portion  raises  it  obliquely  forward,  the  posterior  por- 
tion obliquely  backward.  It  raises  it  as  far  as  the  horizontal,  beyond 
which,  the  arm  being  fixed  by  the  deltoid  against  the  scapula,  it  is 
raised  by  the  rotation  of  the  scapula.  Paralysis  is  easily  recognized : 
If  the  muscle  is  relaxed,  there  is  subluxation  of  the  humerus,  par- 
ticularly if  at  the  same  time  the  supraspinatus  is  paralyzed ;  if  the 
deltoid  is  atrophied,  the  contour  of  the  bones  at  the  shoulder  shows 
plainly. 

M.  supraspinatus  (N.  suprascapularis  from  the  supraclavicular  por- 
tion of  the  brachial  plexus)  assists  the  deltoid  in  raising  the  arm  out- 
ward toward  the  front,  rolls  it  inward,  it  is  also  said  to  hold  the  head 
of  the  humerus  in  its  socket  when  the  arm  is  raised. 

Mm.  infraspinatus  (N.  suprascapularis)  and  the  teres  minor  (N. 
axillaris)  roll  the  upper  arm  outward. 

M.  subscapularis  (N.  subscapularis  from  the  brachial  plexus)  is  a 
rotator  inward.  Paralysis  of  a  rotator  allows  the  arm  to  rotate  in  the 
opposite  course ;  in  testing,  we  first  make  passive  rotation,  and  letting 
the  arm  fall,  allow  it  actively  to  do  the  same  thing,  while  we  oppose 
the  rotation. 

M.  pectoralis  major  (N.  thoracic,  anti.  of  the  brachial  plexus)  ad- 
ducts  the  upper  arm ;  when  the  arm  is  raised  up,  it  moves  it  forward 
in  the  horizontal  plane,  draws  the  arm  down  when  it  is  raised.  Test: 
Have  the  upraised  arm  moved  forward  in  a  horizontal  plane  while  we 
offer  resistance. 

M.  latissimus  dorsi  (N.  thoracico-dorsalis  from  the  brachial  plexus) 
draws  down  the  arm  when  it  is  raised  up  in  exertion,  [it  depresses  it], 
and  draws  it  backward.  When  the  arm  hangs  down  it  draws  it  back- 
ward and  inward  [toward  the  buttock].  Test:  The  arm  is  raised  to 
the  horizontal  and  the  effort  is  made  to  lower  it  while  the  movement 
is  opposed.  The  teres  major  materially  assists  the  latissimus  ;  it  is  at 
the  same  time  a  rotator  inward. 

Mm.  coraco-brachialis  (N.  musculo-cutaneous  of  the  median)  and 
anconeus  longus  (cap.  long,  tricipitis ;  N.  radial.),  when  the  arm  is 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  543 

drawn  down  by  the  latissimus  and  pectoralis,  hold  the  head  of  the 
humerus  up  and  firmly  in  its  socket. 

(c)  Muscles  from  the  upper  arm  to  the  forearm  : 

M.  triceps  (N.  radialis)  is  an  extensor  of  the  forearm. 

M.  brachialis  internus  (N.  musculo- cutaneus)  is  a  simple  flexor. 

M.  biceps  (N.  rausculo-cutaneus)  flexes  and  supinates. 

M.  supinator  longus  (N.  radialis)  flexes  and  pronates.  This  is 
proved  by  having  the  modeVately  pronated  forearm  flexed  while  the 
movement  is  resisted.  If  it  is  healthy,  it  rises  up  like  a  hard  roll  on 
the  outer  side  of  the  elbow-joint. 

We  here  next  mention  the  pronators :  the  pronator  teres  (it  is  at 
the  same  time  a  flexor)  and  quadratus,  both  supplied  by  the  median 
nerve. 

(c?)  Muscles  which  extend  from  the  condyles  of  the  humerus  and 
the  bones  of  the  forearm  to  the  hand  and  fingers,  and  the  small  mus- 
cles of  the  hand  :  ^ 

The  extensor  carpi  radialis  longus  and  brevis  (N.  rad.)  +  extensor 
carpi  ulnar.  (N.  rad.)  are  elevators  of  the  hand.  The  flexor  carpi 
radialis  (N.  median)  +  flexor  carpi  ulnaris  (N.  ulnar.)  are  volar  flexors 
of  the  hand ;  the  palmaris  longus  (N.  median.)  assists  in  this  action. 

The  extensor  carpi  radialis  longus  -{-  flexor  carpi  radialis  adduct 
the  band  in  the  direction  of  the  radius.  Extensor  carpi  ulnaris  + 
flexor  carpi  ulnaris  adduct  the  hand  on  the  ulnar  side.  If  the  exten- 
sor carp.  rad.  long,  acts  alone,  it  raises  the  hand  obliquely  on  the 
radial  side,  as  the  ext.  carp.  uln.  does  on  the  ulnar  side. 

Paralysis  of  the  extensors  of  the  hand  (or  especially  lead-paralysis, 
also  sleep-paralysis  of  the  N.  radialis)  allows  the  hand,  when  the  fore- 
arm is  pronated,  to  hang  loosely  down.  Paralysis  of  the  abductors 
and  adductors  and  also  paralysis  of  the  extensores  c.  radial,  long,  and 
carpi  ulnaris  alone,  produces  oblique  position  of  the  hand  [paralysis 
from  the  former  giving  a  position  opposite  to  that  of  the  latter].  We 
test  the  individual  movements  by  successively  opposing  them. 

M.  extensor  digitorum  (communis  indicator,  exte.  digiti  V,,  all  from 
the  N.  radial)  extend  the  first  phalanges. 

M.  flexor  digitor.  coram,  sublim.  (N.  median.)  flexes  the  middle 
phalanges;  M.  flexor  digitor.  coram,  prof.  (N.  media,  the  two  ulnar 
bellies  from  N.  ulnar.)  flexes  the  terminal  phalanges.  Mm.  inteross. 
dors,  4-  volares  (N.  ulnar.)  and  Mm.  lumbricales  (N.  med.  and  ulnar.) 


544  SPECIAL  DIAGNOSIS. 

flex  the  first  phalanx  and  at  the  same  time  extend  the  middle  and 
terminal  phalanges. 

Mm.  inteross.  dors,  alone  abduct  (spread  apart),  volares  alone  adduct 
the  (middle  :  third)  finger. 

Movements  of  the  thumb  :  extensor  pollic.  long.  (N.  rad.)  is  essen- 
tially an  extensor  of  both  phalanges ;  extens.  poll.  brev.  (N.  rad.)  is  an 
extensor  only  of  the  first  phalanx.  Adductor  poll.  long.  (N.  rad.) 
abducts  the  metacarpus.  Flexor  poll.  long.  (N.  med.)  flexes  the  term- 
inal phalanx.  At  the  thenar  are  the  opposing  muscles — abductor 
poll,  brevis,  outer  head  of  the  flexor  brevis,  and  the  opponens  poll, 
(all  from  the  N.  med.).  Adductors:  adductor  poUicis  and  the  inner 
deep  head  of  the  flex.  brev.  (both  N.  ulnar.)  These  two  and  the 
abductor  brev.  flex  the  first  and  extend  the  terminal  phalanx. 

The  adductor,  flexor,  and  opponens  act  at  the  hypothenar,  their 
names  indicating  their  action.     All  are  innervated  by  the  N.  ulnaris. 

Chai'acteristic  positions  of  the  hand  and  fingers :  1.  In  paralysis  of 
the  ulnar  there  is  the  clawing,  clutching  hand,  7nain  en  griff e :  the 
first  phalanges  are  extended,  the  middle  and  terminal  ones  flexed 
(paralysis  of  the  interossei),  the  thumb  hangs  helpless  over  the  hand 
(paralysis  of  the  adductor) ;  the  fingers  are  easily  spread  out  (action 
of  the  extensores  digit.).  Thus  the  interosseal  spaces  on  the  dorsum 
are  deepened,  likewise  the  groove  between  I.  and  II.  metacarpal  bones 
(atrophy  of  the  adductor  pollicis,  deep  head  of  the  flexor  brevis  and 
inteross.  dorsi  I ).  The  hypothenar  is  atrophic.  2.  In  paralysis  of 
the  thenar  (deep  median  paralysis)  there  is  the  ape-hand :  the  thumb 
does  not  stand  out  opposing,  but  is  parallel  with,  the  other  fingers. 

Paralysis  of  the  extensors  of  the  hand  causes  apparent  weakness  of 
the  long  flexors  of  the  fingers,  because  the  origin  and  insertion  of  the 
flexors  are  brought  near  together  by  the  flexion  of  the  hand  at  the 
wrist.  Hence,  we  must  passively  extend  the  wrist  and  then  test  the 
flexion  of  the  fingers.  For  the  same  reason  it  is  necessary,  when  there 
is  paralysis  of  the  long  extensors  of  the  fingers,  to  passively  extend 
the  first  phalanx  before  testing  the  flexion  of  the  middle  and  terminal 
phalanges. 

Examination.  We  observe  the  position  of  the  hand  for  possible 
atrophy.  Then  we  test  extension,  flexion,  abduction  and  adduction 
at  the  wrist — sometimes  all  of  these — by  resisting  these  motions ;  then 
the  extension  of  the  fingers;  next  the  long  flexors  by  "hooking"  of 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  545 

the  fingers ;  then  let  the  patient  make  the  separate  motions  of  the 
interossei  muscles ;  flex  the  first  phalanx  with  the  middle  and  end 
phalanges  extended ;  then  spread  out  and  close  the  fingers ;  test  the 
muscles  of  the  thenar  and  hypothenar  by  bringing  the  thumb  and 
little  finger  into  contact ;  lastly,  the  examiner  places  his  own  index 
finger  in  the  saddle  between  the  thumb  and  the  second  metacarpus, 
while  the  patient  makes  simple  adduction  of  the  thumb,  thus  testing 
the  power  that  is  manifested.  Pressure  of  the  hand  is  a  very  prac- 
tical way  of  making  a  general  test  of  the  long  flexors  and  the  small 
muscles  of  the  hand. 

For  such  paralyses  as  are  not  wholly  diffuse,  but  rather  confined  to 
individual  muscles  or  gr6ups  of  muscles,  peripheral  and  certain  spinal 
paralyses,  it  has  value  only  as  a  preliminary  examination.  For  various 
reasons  we  consider  the  dynamometer  as  an  unnecessary  apparatus 
and  one  that  does  not  accomplish  its  purpose. 

It  cannot  be  sufficiently  insisted  upon  that  in  order  to  establish  the 
diagnosis  exactly  in  the  upper  extremity,  and  particularly  in  the  hand, 
beside  a  clear  conception  regarding  the  location  and  physiological 
action  of  the  muscles,  there  must  be  a  knowledge  of  their  innervation. 
We  observe,  especially,  how  the  ulnar  and  median  are  distributed  in 
the  small  muscles  of  the  hand.  The  former  innervates  the  hypothenar, 
interossei,  the  two  ulnar  lumbricales,  and  the  adductors  of  the  thenar, 
adductor  pollicis,  and  the  deep  head  of  the  flexor  brevis ;  the  latter, 
the  remaining  muscles.  In  the  hand,  the  radial  only  supplies  branches 
to  the  skin. 

9.  Muscles  of  the  lower  extremity. 

(a)  Muscles  from  the  pelvis  to  the  thigh  : 

M.  ileo-psoas  (N.  crural  from  the  lumbar  plexus)  flexes  the  hip- 
joint  ;  it  is  assisted  (and  in  the  sense  of  pure  flexion)  by  the  action  of 
tensor  fasciae  latse  (N.  gluteus  super,  from  ischiadic  plexus).  In 
paralysis  of  the  psoas,  or  of  this  and  the  tensor  fasciae,  it  is  not  pos- 
sible to  flex  the  thigh  either  in  walking  or  in  bed ;  paralysis  of  the 
tensor  fasciae  alone  permits  the  pure  psoas  action  to  take  place : 
flexion  with  rotation  outward. 

M.  gluteus  max.  (N.  glut,  inferior  or  plexus  ischiad.)  extends  the 
thigh ;  when  the  thigh  is  fixed,  it  brings  the  pelvis  to  the  horizontal 
position,  and  thus  the  trunk  to  the  vertical  (into  the  upright  from  the 
stooping  posture,  standing  upright,  etc.).     When  it  is  paralyzed,  there 

35 


546  SPECIAL  DIAGNOSIS. 

is  the  peculiar  kind  of  action  in  rising  from  the  floor  described  on 
page  539,  with  paralysis  of  the  extensors  of  the  trunk. 

M.  gluteus  medius  (N.  glut.  sup.  from  the  plexus  ischiad.),  abduc- 
tor ;  M.  gluteus  minim,  (same  nerve)  rotates  the  thigh  inward.  The 
three  glutei  are  the  most  important  supporters  of  the  pelvis. 

M.  piriformis  (plex.  isckiad.),  M.  obturator,  int.  (N.  ischiad.),  M. 
gemelli  (N.  ischiad.),  M.  obturator  exter.  (N.  obturat.,  plex.  lumbal.), 
M.  quadrat,  femor.  (N.  ischiad.),  are  all,  in  reality,  out-rotators. 

M.  adductor  long.,  brev.,magn.,  pectineus  and  gracilis  (N.  obturat., 
plex.  lumb.),  are,  for  the  most  part,  adductors,  at  the  same  time  partly 
flexors.     The  eff"ect  of  their  paralysis  is  clear. 

(5)  Muscles  from  the  pelvis  and  the  femur  to  the  leg : 

M.  quadriceps  (N.  crural.)  extends  the  leg;  its  long  head,  the 
rectus,  arises  from  the  pelvis  (anter.  infer,  spine),  and  hence  acts 
with  more  power  when  the  thigh  is  in  a  position  of  extension  with 
reference  to  the  pelvis.  In  paresis  of  the  quadriceps,  the  leg  (or  pos- 
sibly both  legs)  in  walking  are  frequently  set  forward,  flexed  more 
markedly  at  the  knee-joint  (the  leg  during  the  forward  movement  of 
the  limb  hangs  vertically  down),  and  this  is  true  also  when  it  is  set 
down  quickly,  so  that  there  is  a  sort  of  snapping  of  the  knee-joint 
into  the  position  of  extension.  The  examination  is  best  made  by 
endeavoring  to  flex  the  limb  when  it  is  actively  extended. 

M.  sartorius  (N.  crural.)  is  probably  chiefly  an  inward  rotator  of 
the  flexed  leg. 

Mm.  biceps  fem.,  semitendinos.,  and  semimembranos.  (N.  ischiad.) 
flex  the  knee-joint ;  the  first  rotates  the  flexed  leg  outward,  the  second 
inward.  If  the  limb  is  powerfully  extended  by  the  quadriceps,  then 
these  flexors,  as  well  as  the  gluteus  max.,  act:  they  place  the  pelvis 
in  the  horizontal  position  (important  in  walking). 

(c)  Muscles  from  the  leg  (or  the  condyles  of  the  femur)  to  the  foot 
and  toes : 

M.  gastrocnemius,  soleus,  plantaris  (N.  tibial.)  are  extensors ;  that 
is,  are  plantar  flexors  of  the  foot,  and,  at  the  same  time,  adductors  of 
the  extended  foot. 

Mm.  peroneus  long,  and  brev.  (N.  peroneus)  are  extensors  (chiefly 
the  first)  and  adductors  of  the  foot,  lift  up  the  outer  border  of  the  foot. 
In  paralysis  of  the  peronei  muscles  (by  "  peroneus-paralysis  "  we  mean 
paralysis  of  the  whole  peroneus  nerve :  see  below,  under  M.  tibialis 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  547 

antic.) ;  the  foot  in  extension,  as  well  as  flexion,  stands  in  the  position 
of  adduction  and  the  outer  border  of  the  foot  is  deeper ;  the  foot 
becomes  flat.  It  is  not  easy  to  test  the  activity  of  the  peronei :  we 
must  first  show  the  patient  the  movements  of  abducting  and  lifting 
up  the  outer  border  of  the  foot  by  passive  movements,  and  then  have 
him  repeat  them ;  besides,  we  have  the  patient  extend  the  foot : 
in  paralysis  of  the  peroneus  longus  decided  adduction  then  takes 
place. 

M.  tibial,  ant.  (N,  peroneus)  flexes ;  that  is,  dorsally  flexes  and 
adducts  the  foot ;  M.  extensor  digit,  comm.  and  extens.  halluc.  long. 
(N.  peron.)  flexes  and  adducts  the  foot,  extends  the  toes.  Paralysis 
of  the  dorsal  flexors  causes  the  point  of  the  foot  to  drop  when  the  foot 
is  lifted  from  the  floor.  If  the  peronei  are  likewise  paralyzed  (pero- 
neal paralysis ;  that  is,  paralysis  of  the  peroneus  nerve),  then  the  foot 
is  lax  at  the  ankle-joint ;  the  point  of  the  foot  hangs  down,  with 
inclination  to  adduction.  In  walking  we  observe  that  the  foot,  as  it 
is  raised  from  the  floor,  makes  a  peculiar  shuffling  motion  inward,  and 
it  is  set  down  in  a  fumbling  manner.  Persons  with  unilateral,  isolated 
peroneal  paralysis  are  always  inclined  to  take  a  longer  step  with  the 
disabled  limb  in  order  to  obtain  the  sweeping  motion  required  for  the 
awkward  placing  of  the  foot  upon  the  floor. 

M.  tibial,  postic.  (N.  tibial.)  is  an  adductor. 

Mm.  flexor  digitor.  comm.  long,  and  brev.  (N.  tibial.)  are  flexors 
of  the  middle  and  terminal  phalanges  of  the  toes  ;  Mm.  interossei 
externi  interni  (N.  tib.)  are  flexors  of  the  first,  extensors  of  the 
middle  and  terminal  phalanges — interossei  externi.  [The  outer  three 
muscles  are  abductors  of  the  second,  third,  and  fourth  toes,  respect- 
ively, Avhile  the  first  is  an  adductor  of  the  second  toe,  and  assists  the 
plantar  interossei.] 

Paralysis  of  the  interossei  causes  a  peculiar  kind  of  claw-position 
exactly  analogous  to  that  of  the  fingers  (see  p.  544). 

M.  extensor  halluc.  longus  (N.  peron.)  extends  the  first  phalanx  of 
the  great  toe ;  Mm.  adductor,  flexor  brevis,  abductor  hallucis  (N.  tib.) 
act  essentially  in  accordance  with  their  names :  they  produce  simul- 
taneously flexion  of  the  first  and  extension  of  the  terminal  phalanx. 
Paralysis  of  the  flexor  of  the  great  toe  hinders  one  in  walking,  but 
especially  in  springing. 


548  SPECIAL  DIAGNOSIS. 

Disturbances  of  Speech  (Lalopathy). 
I.  Dysarthria  and  Anarthria. 

Bj  these  expressions  we  understand  those  disturbances  of  speech  in 
which  we  see  it  altered  in  the  same  way  as  the  activity  of  a  joint  is 
distributed  as  to  its  motility :  by  paresis,  paralysis,  trembling,  spasm, 
and  even  ataxia  of  the  vocal  muscles. 

Unilateral  paralysis  of  the  muscles  of  speech  occurs  in  unilateral 
affections  of  the  pyramidal  tract  above  the  medulla  oblongata,  or  of 
the  cortical  centre  of  the  motor  speech  muscles  ;  likewise  in  peripheral 
paralysis  of  the  hypoglossus  and  facial  nerves.  At  first  the  speech  is 
decidedly  disturbed ;  if  these  affections  continue,  there  occurs  a 
considerable  improvement  in  the  speech,  as  if  it  were  re-acquired  by 
practice.  Bilateral  paralyses  generally  occur  from  the  bulbus  of  the 
oblongata  (bulbar  paralysis),  and  are  then,  if  they  are  ganglion 
paralyses,  degenerative-atrophic.  It  is  rare  to  have  bilateral  speech 
paralysis  from  bilateral  cortical  or  pyramidal  lesion  (pseudo-bulbar 
paralysis).  We  also  rarely  have  a  bilateral  paralysis  of  the  hypo- 
glossus or  facial  nerves  of  peripheral  origin. 

For  the  muscles  that  produce  speech  and  their  innervation,  see 
above,  pp.  536  and  537.  Depending  upon  which  muscles  are  paralyzed, 
the  disturbance  of  speech  may  vary  with  different  letters,  as  mentioned 
at  the  above-named  place.  We  recognize  slight  anarthritic  disturb- 
ances of  speech  by  requiring  the  patient  to  pronounce  difficult  words 
quickly,  especially  such  as  contain  many  consonants.  Simultaneously 
with  this  disturbance  of  speech,  the  voice,  from  paralysis  of  the  palate, 
is  often  nasal  (or  also  a  kind  of  "  clod-voice  "),  or  the  voice  has  a 
monotone,  or  it  is  inclined  to  change  to  a  falsetto.  (Regarding  swal- 
lowing, see  p.  537.) 

Scanning  speech :  sounding  like  the  speech  of  a  rider  of  a  horse 
that  is  trotting ;  there  are  sharp  changes  of  rhythm,  unnatural 
pauses,  sudden,  "  explosive,"  and  then,  again,  snapping  pronunciation 
of  words.     It  is  particularly  characteristic  of  multiple  sclerosis. 

Hysterical  dumbness  is  a  complete  loss  of  speech  and  generally  also 
of  the  voice,  which  occurs  suddenly,  and  generally  after  an  attack  of 
hysteria,  which  lasts  anywhere  from  days  to  years,  and  may  suddenly 
disappear.     The  mobility  of  the  tongue  is  normal. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  549 

II.  Apliasic  Disturbances,  Disturbance  of  Graphic  Communication 
{of  Mimicking,  of  Singing). 

In  order  to  understand  these  conditions  it  is  necessary  to  make 
some  explanations  regarding  the  acquisition  and  use  of  speech,  of 
writing,  etc. 

Speech  and  its  related  functions  have  their  foundation  in  the  culti- 
vated memory,  which  is  acquired  by  much  practice,  and  for  the  mother 
tongue  in  childhood.     We  acquire  such  a  development  of  the  memory : 

1.  For  speech  in  the  narrow  sense,  and  it  comprises: 

(a)  Cultivation  of  acoustic  memory,  acquaintance  with  the  sound  of 
words  by  hearing  letters,  words,  and  sentences  spoken  by  others. 

(b)  Cultivation  of  the  motor  memory,  the  complex  motions  used  in 
speaking  words,  by  imitating  what  we  hear,  trying  to  produce  the 
same  by  correcting  what  the  organs  of  speech  produce  until  we  attain 
the  desired  degree  of  perfection,  and  we  treasure  up  [in  the  memory] 
the  complex  motions  which  are  required  for  accomplishing  what  is 
desired. 

2.  The  memory  for  writing  comprises  the  cultivation  of  the  optic 
memory,  the  acquisition  of  writing,  and  the  complex  motor  writing- 
motions — again  by  imitating  what  we  see. 

Likewise,  we  develop  the  comprehension  and  reproduction  of  music, 
a  very  individual  faculty ;  of  mimicry,  and  of  gestures,  varying 
according  to  the  nationality. 

Simultaneously  with  speech,  or  always  somewhat  later  than  imita- 
tion of  what  is  heard,  ideas  develop — the  concrete  first;  upon  the 
foundation  of  the  concrete,  the  abstract. 

Now,  we  suppose  that  the  cultivation  of  the  sound  of  words,  and  of 
their /orm,  also  the  complex  motions  for  speaking  as  well  as  writing 
them,  these  four  to  be  accumulated  each  at  its  own  place  in  the  brain- 
cortex  ;  but  that,  presiding  over  all,  yet  not  concentrated  at  one  place, 
but  as  the  result  of  innumerable  functions,  with  numberless  tracts 
connected  with  the  cells  of  the  brain- cortex,  is  the  mind — intelli- 
gence. The  representations  of  memory,  and  the  complex  motions 
(which  are  likewise  representations  of  memory),  can  only  functionate 
the  nervous  tissue — that  is,  can  only  be  represented  as  tones,  chords, 
a  series  of  tones  and  chords  of  a  violin. 

And  in  fact  they  can  be  innervated : 


550  SPECIAL  DIAGNOSIS. 

1 .  From  the  representations  of  the  sound  of  words  :  these  come 
from  the  periphery  through  the  sense  of  hearing.  If  we  hear  the 
mother  tongue  (or  any  other  language  which  we  know),  from  the  con- 
ception, we  inwardly  pronounce  the  words. 

2.  From  the  written  representation  :  from  the  periphery — that  is, 
from  the  organ  of  sight,  if  we  read  in  a  known  language ;  and  from 
the  conception,  if  we  inwardly  represent  to  ourselves  the  printed  or 
written  word. 

2>.  From  the  complex  motions  of  speech  :  from  the  centre  repre- 
senting the  sound  of  words  by  virtue  of  the  imitative  instinct — repeti- 
tion ;  and  from  the  mental  conceptions — independent  utterance  of 
thought. 

4.  From  the  complex  motions  of  writing  :  from  written  words,  by 
virtue  of  our  imitative  instinct — copying  ;  from  mental  conceptions — 
writing  out  the  thought. 

But  still,  this  is  not  all :  the  impulse  to  produce  the  complex  motions 
of  speech  may  come  from  the  written  or  printed  representation — we 
read  aloud.  On  the  other  hand,  the  impulse  to  make  the  complex 
motions  of  writing  may  come  from  what  is  heard — we  write  from  dic- 
tation. Further,  while  we  are  speaking  or  writing,  there  comes  along 
the  muscular  sense  an  innervation  (going  in  a  centripetal  direction)  of 
the  complex  motions  of  speech  or  writing.  We  can  make  this  clear 
if,  with  the  eyes  closed,  we  have  someone  else  move  our  hand,  as  if 
writing  a  word :  by  this  means,  without  other  assistance,  we  can  recog- 
nize simple  words.  In  a  still  higher  degree,  also,  in  the  active  motions 
of  writing  and  speaking  the  report  of  what  is  written  or  spoken — that 
is,  the  contractions  of  the  muscles  taking  part  in  these  acts,  and  the 
motions  produced  by  them,  go  centripetally  to  the  brain. 

The  conceptions  of  musical  notes  seem  to  coordinate  those  of  word- 
sounds,  while  the  complex  motions  for  producing  speech  and  those 
which  produce  music  (melody  and  rhythm) — that  is,  for  singing — are  co- 
ordinated with  the  larynx  and  mouth.  The  conceptions  of  musical 
sounds  are  intimately  connected  with  those  of  word-sounds,  and  the  com- 
plex motions  required  in  singing  are  connected  with  those  required  in 
speaking.  The  intimateness  of  this  association  appears  very  distinctly 
in  the  fact  that  when  a  melody  happens  to  come  to  mind  we  hum  the 
words  belonging  to  it;  or,  if  the  words  come  first,  then  we  hum  the 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  55X 

melody.  Sometimes  this  humming  is  a  purely  automatic  act,  for  both 
the  text  and  the  melody  are  articulated  involuntarily  together.  But, 
again,  sometimes  the  internal  re-sounding  follows  the  articulation  or 
act  of  listening,  and  from  this  internal  impression  the  articulation  is 
first  produced. 

Now,  to  these  innervations  there  belong  tracts  of  communication. 
Those  conducting  from  the  periphery  to  the  "  sensory "  centres, 
leading  to  the  centres  for  conceptions  of  sound  and  writing,  we  under- 
stand very  well — the  acoustic  and  optic  nerves.  Further,  there  must 
exist  very  manifold  combinations  between  the  conception  and  the  four 
different  centres  themselves  [mentioned  on  p.  550],  but  it  is  very 
difficult  to  obtain  an  exact  presentation  of  these  combinations. 

For  instance,  Kussmaul  supposes  that  the  tract  from  the  centre  of 
ideas  to  that  for  the  complex  motions  of  speech  goes  through  the 
portion  which  takes  note  of  the  sound  of  the  word  ;  hence  he  assumes 
no  direct  innervation  of  the  centre  of  the  complex  motions  of  speech 
from  that  of  ideas.  Likewise,  there  is  a  dispute  whether  there  is  a 
direct  communication  from  the  written  representation,  or  whether 
there  is  a  communication  with  the  centre  for  the  complex  motion  of 
writing,  etc.,  only  through  another  centre.  We  will  only  bring  forward 
one  instance,  for  the  sake  of  illustration.  The  following  acts,  done 
without  understanding  by  persons  in  health  as  well  as  by  sick  persons 
— repeating,  reading  aloud,  copying,  or  writing  from  dictation — make 
it  plausible  that  direct  communication  exists  between  the  sensory  and 
motor  centres,  which,  therefore,  do  not  go  through  the  centre  for 
ideas.  But  there  is  no  doubt  that,  in  regard  to  this,  there  are  very 
considerable  individual  differences,  particularly  dependent  upon  the 
degree  of  cultivation  and  the  intelligence. 

Of  course,  we  also  understand  the  tracts  which  peripherally  lead 
from  the  "motor  speech-  and  writing-centres  " — they  go  through  the 
pyramidal  tracts,  the  bulbar  nucleus,  to  the  individual  motor  nerves; 
and,  finally,  we  have  a  general  presentation,  at  least,  of  the  tracts 
which  pass  centripetally  from  the  muscles  and  joints. 

These  very  different  qualities,  acquired  by  practice,  may  each  singly 
or  several  together  be  lost.  When  the  organ  of  hearing  remains  per- 
fectly intact,  the  innervation  from  the  periphery  of  the  conception  of 
the  sound  of  words — that  is,  the  ability  to  understand  the  words  of  one's 
native  tongue — may  be  lost :   there  is  word-deafness  ["  inability  to 


552  SPECIAL  DIAGNOSIS. 

understand  spoken  words,  although  they  are  heard  as  sounds,  while 
printed  or  written  words  are  understood" — Billings],  loss  of  intellectual 
perception  of  sounds.  Even  when  the  muscles  of  speech  are  perfectly 
normal,  the  ability  to  employ  language,  to  express  one's  ideas  through 
the  innervation  which  results  in  the  complex  motions  necessary  to  make 
use  of  the  appropriate  word  in  the  native  language,  may  be  lost :  motor 
or  ataxic  aphasia  (or,  as  Kussmaul  designates  it,  "the  purest  form  of 
ataxic  aphasia").  The  arm  may  be  in  perfect  condition,  and  yet  we 
may  not  be  able  to  write ;  or  the  eyes  may  be  intact,  and  yet  we 
cannot  read — agraphia,  alexia.  But  since  the  different  capacities 
under  consideration — the  understanding  and  formation  of  words,  the 
understanding  and  production  of  writing — are  in  a  very  manifold  way 
connected  with^  each  other,  these  disturbances  almost  never  occur 
singly,  but  as  a  complex  of  disturbances. 

The  expressions — '•'•acoustic  amnesia''  for  word- deafness,  ^^  visual 
amnesia"  for  loss  of  intellectual  perception  of  sounds — seem  to  us  to 
be  very  useful,  more  so  than  the  German  designations  formed  upon  a 
different  principle.  The  only  objection  is  that  these  expressions  may 
be  confounded  with  the  idea  of  amnesia  discussed  later  on  (p.  554). 

The  study  of  these  things  has  proceeded  from  the  observations  of 
the  disturbances  of  speech  in  the  narrowest  sense,  that  is,  of  speaking 
(Boilliaud,  M.  Dax,  Broca).  For  this  reason,  and  because  all  dis- 
turbances that  come  under  consideration  apply  to  speech  in  the  broader 
sense  (spoken  and  written  speech,  with  reference  to  its  comprehension 
and  production),  we  class  together,  not  at  all  incorrectly,  all  the 
conditions  under  consideration,  by  the  designation  of  aphasia,  aphasie 
disturbances. 

We  only  mention  now  those  two  manifestations  which  may  be  most 
sharply  distinguished,  while  for  all  the  details  we  refer  to  the  special 
works  (see,  also,  the  "schema"  of  Lichtheim). 

1.  Word-deafness  (Kussmaul),  sensor?/  aphasia  (Wernicke).  The 
two  ideas  are  not  wholly  identical.  Special  works  show  this  more  at 
length.  The  patient  hears  every  word,  but  it  sounds  to  him  as  any 
healthy  person  hears  a  word  that  belongs  to  a  language  which  is 
wholly  strange  to  him.  The  mother  tongue,  so  far  as  the  under- 
standing of  the  hearer  is  concerned,  has  become  a  foreign,  unknown 
tongue ;  also,  ability  to  repeat  and  to  write  from  dictation  is  wanting. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  553 

But,  again,  sometimes  the  understanding  of  writing  may  fail  {alexia), 
and  with  it  the  ability  to  read  aloud  (see  p.  558). 

But,  in  opposition  to  this,  the  power  of  volitional  writing  and  to 
copy  written  characters,  and  further,  volitional  speech,  is  preserved. 
Nevertheless,  we  generally  observe  a  disturbance  in  this  also :  very 
often  the  wrong  words  are  used,  because  words  that  are  related  by 
sense  or  sound  are,  from  unrestrained  association,  pronounced  and 
strung  together  [parajjhasia) ;  or,  it  may  be  distinctly  noticed  that  the 
correct  words  are  employed,  but  they  are  distorted  by  repetition  of 
syllables,  dropping  of  syllables,  transposition  of  letters  or  syllables 
{literal  ajyhasia,  syllable- stumbling).  Moreover,  both  conditions  some- 
times have  relation  with  amnesia  (''  amnestic  ojphasia,''  see  p.  556). 

2.  Atactic  ajyhasia  (Broca's  aphemia,  Wernicke's,  motor  aphasia) 
consists  in  this,  that  the  patient  is  unable  to  communicate  his 
thoughts  by  words:  he  cannot  name  objects  presented  to  him, 
although  he  promptly  shows  that  he  recognizes  what  they  are  in  that 
he  knows  how  to  use  them  correctly ;  at  the  same  time  there  is  dim- 
inution of  the  power  to  voluntarily  write,  or  to  write  down  what  is 
heard  (or  write  from  dictation) :  agraphia,  with  the  exception  of  the 
ability  to  transcribe  from  copy,  which  is  usually  retained.  Thus,  in 
pure  cases,  there  is  perfect  understanding  of  what  is  said  and  also  of 
what  is  written,  and  hence  there  is  neither  word-blindness  nor  word- 
deafness. 

But  in  one  respect  the  condition  of  most  patients  of  this  character 
is  still  somewhat  obscure :  with  reference  to  the  question  whether  they 
are  able  to  produce  the  sound  of  the  word  mentally,  to  conceive  of  its 
sound,  i.e.,  to  mentally  sound  the  word.  According  to  Lichtheim,  it 
is  probable  that  in  most  or  in  all  such  cases  this  capacity  has  also  been 
completely  lost.  But  regarding  this  point  it  is  very  diflficult  to  form  a 
positive  opinion  Avith  respect  to  these  patients. 

We  cannot  refrain  from  dwelling  a  little  upon  this  question.  (For 
further  regarding  the  examination  of  patients  with  aphasia,  see  below.) 
We  must  confess  that,  in  these  cases,  we  have  found  that  the  method 
employed  by  Lichtheim,  though  it  is  ingenious,  is  very  uncertain. 
Lichtheim,  in  order  to  determine  whether  the  word  which  designates 
the  given  object  is  mentally  correctly  sounded,  requires  the  patient  to 
tell  how  many  syllables  there  are  in  the  word,  or  to  press  the  hand  as 
many  times  as  it  contains  syllables.     It  is  assumed  that  when  an  object 


554  SPECIAL  DIAGNOSIS. 

is  presented  to  a  patient  there  arises  in  his  mind  a  conception  of 
the  sound.  What  designation  does  he  think  of  ?  I  hold  up  a  knife 
before  him — does  he  think  ''a  pocket-knife"  or  "knife?" — a  drink- 
ing-glass:  " a  drinking-glass "  or  a  "glass?" — "handkerchief"  or  a 
"sackcloth?"  I  admit  that  there  are  substances  about  which  there 
is  no  doubt,  but  one  would  be  easily  inclined  to  hold  that  the  number 
of  syllables  was  wrong,  and  yet  the  patient  thought  he  had  understood 
and  had  spoken  correctly. 

Slighter  forms  of  atactic  aphasia  manifest  only  a  slight  defect  in 
the  command  of  lano-uao-e  :  single  words  are  omitted  or  sino;le  words 
are  defectively  pronounced:  "doltor,"  "dolner,"  for  doctor;  "lit," 
for  lip;  I  am  "benter,"  for  better,  etc. — that  is,  there  is  a  literal 
ataxia,  syllable-stumbling.  But  often  the  patient  dwells  upon  only  a 
few  words,  or  only  one,  or  even  a  single  syllable,  which  is  constantly 
employed  for  everything,  as  was  the  case  with  a  patient  reported  by 
Striimpell,  and  whom  we  have  watched  for  years,  who  could  only  say, 
"bibi,  bi-bi-bi-bi-bi."     We  also  have  cases  of  paraphasia. 

An  atactic-aphasic  patient  who,  before  becoming  affected,  was  a 
good  singer,  may  lose  the  power  of  singing  as  well  as  of  speaking,  and 
yet  the  "ea,r"  may  be  retained:  he  hears  Avhen  he  himself  or  some 
one  else  sings  a  false  note.  But  though  the  speech  may  be  lost,  he 
may  still  retain  the  power  to  sing  the  melody  of  a  song,  and  then  it 
may  happen  that  with  the  melody  he  may  automatically  articulate  the 
words  to  which  it  belongs,  although  he  cannot  articulate  them  without 
the  melody.  In  connection  with  this  the  reader  is  referred  to  p.  550 
for  what  was  said  regarding  the  connection  between  the  complex  mo- 
tions of  speaking  and  singing. 

There  is  another  disturbance  which  plays  an  important  part  in  all 
forms  of  aphasia  and  which  presents  a  special  group  of  symptoms  :  it 
is  amnesia,  amnestic  aphasia. 

The  patient  presents  a  perfect  picture  of  a  person  who  is  endeavor- 
ing to  speak  a  foreign  language  which  he  only  slightly  or  very  imper- 
fectly understands.  An  object  is  held  up  before  him  :  he  is  not  able 
to  name  it ;  he  repeats  it  without  understanding  it,  or  he  remarks : 
^•Yes,  certainly,  that  is  the  word;"  or  he  hits  upon  the  correct  word 
through  association,  as  upon  the  number  of  fingers  held  up  before  him 
by  counting — "One,  two,  three,  four — correct:  four."  .  This  amnesis 
manifests  itself  only  with  reference  to  certain  kinds  of  words,  as  for 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  555 

proper  names,  or  chiefly  for  those  representing  the  most  concrete  ideas 
(Kussmaul). 

Amnesia  can  be  mixed  with  the  different  forms  of  aphasia ;  the 
former  may  be  very  indistinct — even  for  a  time,  or  continuously,  may 
predominate  over  the  aphasia ;  but  it  also  occurs  in  all  possible 
conditions  that  do  not  at  all  belono;  here :  senile  dementia,  disease  of 
the  brain  of  all  kinds,  in  convalescence  from  any  very  severe  illness, 
etc.     With  Lichtheim  we  do  not  count  these  cases  as  aphasia. 

Localization  of  the  aphasic  disturbances.  The  exact  localization 
of  the  two  important  centres  of  the  understanding  and  use  of  language 
is  one  of  the  greatest  attainments  of  recent  times. 

The  centre  for  the  complex  motions  employed  in  the  formation  of 
words,  the  motor  speech-centre,  is  located  in  the  left  third  frontal  con- 
volution (Broca) ;  lesion  of  this  point  causes  atactic  aphasia.  The 
centre  for  the  formation  of  sounds,  the  centre  for  acoustic  recollec- 
tions, is  located  in  the  left  anterior  central  convolution  (Wernicke). 
The  right  hemisphere  has  nothing  to  do  with  speech,  except  when  the 
left  side  is  mutilated,  when  it  contains  these  centres  instead  of  the 
left. 

Further,  it  is  extremely  probable,  though  it  cannot  be  regarded  as 
certain,  that  the  centre  for  the  conception  of  writing  is  to  be  looked 
for  in  the  optic  portion  of  the  cortex  of  the  occipital  lobe  (both  sides 
or  only  the  left  ?),  and  the  motor  centre  for  writing  in  the  left  second 
frontal  convolution. 

Hence,  all  these  centres  could  lie  within  the  given  motor  and  sen- 
sory portions  of  the  cortex :  what  relation  they  sustain  to  these  we  do 
not  exactly  know.  We  may  always  conceive  of  them  as  groups  of 
cells  which  are  brought  into  connection  by  tracts  especially  "smoothed" 
by  repetition — that  is,  tracts  with  peculiarly  slight  resistance. 

Mode  of  Procedure  in  Testing  for  Aphasic  Disturbances. 

We  look  for  any  possible  aphasic  symptoms  whenever  there  is 
disease  of  the  brain,  but  especially  with  any  patient  who  has  had 
an  attack  of  apoplexy,  and  particularly  when  there  is  right-sided 
hemiplegia. 

It  is  evident  that  the  examination  of  these  patients  is  often  inter- 
fered with,   either   because    of   their    mental    hebitude — dimness    of 


556  SPECIAL  DIAGNOSIS. 

perception — or  the  inability  to  think,  and  the  loss  of  memory  which 
they  exhibit.  Those  patients  can  only  be  exactly  examined  in 
whom  the  general  effect  of  the  injury  has  passed  oiF;  and  the  most 
interesting  cases  are  those  where,  after  the  indirect  collective  symp- 
toms (see,  respecting  this,  the  last  section  of  this  chapter)  have 
disappeared,  an  aphasic  assemblage  of  symptoms  remains  behind  as 
a  unilateral  disturbance. 

In  the  first  place,  we  ascertain  whether  there  is  amnesia :  if  the 
patient  can,  we  have  him  count,  but  further  we  test  him  by  requiring 
him  to  name  objects  placed  before  him.  If  he  fails  to  do  this,  we  give 
him  the  name  of  the  object  and  have  him  repeat  it.  If  he  can  do  so 
(either  with  or  without  apparent  understanding),  he  is  not  atactic- 
aphasic,  but  amnesic.  It  is  to  be  remarked  that  occasionally  amnesia 
may  simulate  all :  atactic  aphasia,  word-deafness,  word-blindness, 
agraphia. 

We  now  proceed  to  test  for  possible  word-deafness :  by  conver- 
sation, by  requiring  the  patient  to  do  something,  as  to  touch  his  nose, 
or  by  directing  him  to  take  something  in  his  hand — a  knife,  pocket- 
handkerchief,  etc.  We  must  be  careful  to  avoid  making  any  kind  of 
gesture,  also  looking  in  the  direction  of  the  object  named. 

Hereupon  we  look  for  signs  of  atactic  aphasia :  requiring  him 
to  speak  and  to  repeat ;  further  for  evidences  of  paraphasia,  literal 
aphasia.  If  the  patient  is  atactic-aphasic,  then  we  must  always  make 
the  effort  to  discover  whether  he  has  the  internal  sense  of  words  (see 
above). 

After  these  things,  we  conclude  the  test  by  having  him  read  (that 
is,  read  with  understanding),  read  aloud,  have  him  write,  compose, 
write  from  dictation,  copy.  With  persons  who  were  formerly  known 
to  have  had  a  musical  ear,  or  could  sing,  it  will  be  well  to  inquire 
whether  they  retain  or  have  lost  these  powers,  or,  especially,  what 
is  the  relation  of  the  singing  of  the  air  and  hearing  the  music  to  the 
understanding  and  speaking  of  the  words  that  belong  to  it. 

The  diagrams  serve  to  display  the  mutual  relations  of  the  four  cen- 
tres to  each  other  and  to  the  so-called  "  centre  of  perception."  Many 
forms  have  been  prepared,  of  which  we  mention  those  of  Wernicke, 
Kussmaul,  Charcot,  Lichtheim. 

These  diagrams  are  very  useful  for  studying  this  subject  (and  we 
especially  recommend  Lichtheim's).     They  are  a  very  excellent  guide 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 


557 


for  examination,  for  the  clear  understanding  of  the  different  functions, 
and  as  a  stimulus  to  independent  thought.  But  they  do  not  exhibit 
the  actual  facts.  As  a  rule,  these  can  never  be  represented ;  the 
individual  differences  are  too  great.  Charcot  rightly  distinguishes 
persons  as  those  in  Avhom  either  the  conception  of  sound  or  the  con- 
ception of  writing,  or  even  the  mechanical  representation  of  speech  or 
of  writing,  whichever  may,  be  predominant,  serves  as  a  guide  for 
speech  and  writing  (and  likewise  for  understanding  as  well  as  the 
production  of  them).     We  assume  that  in  speaking  as  well  as  writing 

Fig,  166. 


Lichtheim's  diagram  of  aphasia.  A,  centre  for  conception  of  the  formation  of  sound 
(a  A,  conducting  tract) ;  0,  centre  for  conception  of  written  characters  (o  0,  conducting 
tract);  M,  centre  for  the  motions  of  speech  {Mm,  the  centrifugal  motor  tract);  E,  cen- 
tre for  the  motions  of  writing  [Ee,  the  corresponding  motor  tract) ;  B,  centre  for  con- 
ception of  ideas.    The  arrows  indicate  the  direction  of  innervation. 

the  mental  conception  causes  an  innervation  of  the  centre  for  sound 
first,  and  then  this  innervates  the  centre  for  the  complex  motions  re- 
quired in  producing  the  effect  [of  speech  or  writing]  ;  and  further, 
that,  when  writing  is  seen,  it  must  first  innervate  the  centre  for  sound. 
Thus  there  results  the  understanding  of  the  writing,  and  hence  we 
can  form  a  conception  of  what  is  the  significance,  to  such  a  person,  of 
the  loss  of  the  centre  for  the  conception  of  sound :  a  lesion  of  the 
temporal  lobe.  Hence,  in  our  opinion,  if  we  add  to  Charcot's  diagram 
the  centre  of  cognitions,  with  its  manifold  relations,  it  is  the  most 
plausible :  it  includes  all  tracts  that  can  possibly  exist,  and  in  most 


558  SPECIAL  DIAGNOSIS. 

cases  of  aphasia  we  must  assume  that  in  each  individual,  while  in 
health,  some  of  the  tracts  did  not  exist.  Hence,  it  follows  that,  from 
the  character  of  the  disturbance,  whose  location  we  can  know  nothing 
of  without  an  autopsy,  much  less  locate  simply  from  the  symptoms,  we 
must  draw  a  conclusion  regarding  the  tract  from  that  one  which  the 
patient  has  made  use  of  in  health  for  the  purposes  of  speech  (in  its 
widest  sense) ;  and  further,  from  this  we  must  ascertain  what  centres 
or  tracts  are  now  cut  oif. 

It  is  plain  from  this  how  difficult  it  often  is  to  judge  of  these  things 
in  an  individual  case. 

First  we  give  Lichtheim's  and  then  Charcot's  diagram.  After 
Lichtheim's  we  add  his  brief  summary  of  the  possible  disturbances 
and  their  phenomena.  This  summary  does  not  by  any  means  give  an 
idea  of  Lichtheim's  work  upon  aphasia.  Attention  is  here  urgently 
called  to  the  special  works,  particularly  to  the  classical  writings  of 
Charcot,  Wernicke,  Kussmaul,  or  their  pupils,  and  Lichtheim. 

1.  Interruption  in  M^  the  centre  for  the  conceptions  of  motion  or 
the  motor  speech-centre  (atactic  aphasia). 

Lost :  (a)  volitional  speech  ; 

(h)  ability  to  repeat ; 

(c)  "      to  read  aloud  ; 

(d)  "       to  write  volitionally ; 

{e)       "      to  write  from  dictation  [e  [in  the  figure], 
the  internal  conception  of  the  word-sounds). 
Retained  :    (/)  understanding  of  speech  ; 
{g)  "  of  writing ; 

Qi)  ability  to  write  from  copy. 

2.  Interruption  in  A,  the  centre  for  the  conceptions  of  the  sounds 
of  words  (sensory  aphasia). 

Lost :  (a)  understanding  of  speech  ; 

(6)  "  of  writing ; 

{p)  ability  to  repeat  after  one ; 

{d)      "      to  write  from  dictation  ; 

(g)       "      to  read  aloud. 
Retained  :    (/)       "      to  write  volitionally  ; 

{g)       "      to  write  from  copy ;  ^ 

(A)       "      to  speak  volitionally. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  559 

3.  Interruption  of  31  A. 

Intact :  {a)  understanding  of  speech  ; 

(l>)  "  of  writing ; 

((')  ability  to  write  from  copy. 
But  there  is  (a)  paraphasia  ; 

(6)  paragraphia  (the  same  disturbance  in  voluntary 
writing) ; 
disturbance  of  the  same  kind  in — 
(/)  i"epeating  after  one ; 
((/)  reading  aloud ; 
(A)  writing  from  dictation. 

4.  Interruption  of  3fB :  modification  of  motor  aphasia. 
Lost :  {a)  power  of  voluntary  speech  ; 

(5)       "  "         writing; 

— as  in  atactic  aphasia. 
But  intact  are  not  only 

(c)  understanding  of  speech ; 

(t^)  "  of  writing ; 

(g)  ability  to  write  from  copy  ; 
but  besides  (/)       "      to  repeat  what  is  said; 

(g)       "      to  write  from  dictation ; 

(A)       "      to  read  aloud. 

5.  Interruption  of  Mm :  modification  of  motor  aphasia. 
Lost :  All  speech  ;  everything  else  intact. 

6.  Interruption  of  A  B. 

Lost :  (a)  understanding  of  speech ; 

{h)  "  of  writing. 

Disturbed :    {c)  volitional  speech  :  paraphasia. 
Retained:    [d)         "        writing; 

(e)  ability  to  repeat  what  is  said  ; 

(/)       "      to  read  aloud*; 

[g)       "      to  write  from  dictation. 

7.  Interruption  of  A  a. 

Lost :  (a)  understanding  of  speech  ; 

(h)  ability  to  repeat  what  is  said  ; 

(c)       "      to  write  from  dictation. 
Retained :     (d)  power  of  volitional  speech  ; 

(ej        "  "         writing; 


660 


SPECIAL  DIAGNOSIS. 


(/)  understanding  of  writing ; 
{g)  ability  to  read  aloud ; 
(A)       "      to  write  from  copy. 

We  now  introduce  Charcot's  diagram  without  further  explanation. 
Apply  Lichtheim's  Case  1  to  it :  it  will  be  seen  that  in  those  cases 
which  show  that  representation  of  symptoms  perfectly  (Broca's 
aphasia),  it  must  be  assumed  that  Ji^is  diseased;  but  further,  that  in 

Fig.  167. 


Mouth  ? ' 

C 


1!1 


Charcot's  diagram  of  aphasia.  Drawn  by  Marie  {Prog,  med.,  1883).  The  designa^ 
tions  are  the  same  as  in  Lichtheim's  diagram.  Tlie  centres  are  represented  as  being  in 
those  centres  of  the  cortex  where  they  are  to  beloolied  for;  the  light  hatching  around 
A  and  0  indicate  the  general  acoustic  and  optical  field  in  the  cortex.  Notice  the  double 
arrows  upon  all  connecting  lines  between  A,  0,  E,  M.  Also  notice  the  arrows  pointing 
centripetally  toward  Mm  and  Ee,  where  the  stimulation  going  to  M  and  E  cause  the 
motions  of  speech  and  writing.  In  our  opinion  there  is  to  be  added  the  centre  for  ideas, 
which  should  have  a  twofold  connection  with  A,  0,  E,  M. 

health  the  connection  had  passed  from  E  to  A  only  through  M ;  and 
still  further,  that  for  arbitrary  innervation  of  -E'  it  must  have  previously 
gone  from  M,  or  from  A  through  M. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  561 

As  an  addendum,  we  add  here  a  few  remarks  upon  the  diagnostic 
value  of  the  character  of  the  writing  : 

{a)  Writing  is  the  expression  of  thought,  and  in  so  far  as  this  is 
the  case  it  is  a  very  fine  test  for  recognizing  psychical  disturbances 
of  all  kinds.     (See  the  text-books  upon  Psychiatria.) 

(h)  As  was  mentioned  above,  agraphia  belongs  to  the  group  of 
aphasic  symptoms,  and,  in  fact,  it  occurs  in  those  forms  which  are 
completely  analogous  to  disturbances  of  speech  in  the  narrow  sense : 
as  total,  as  partial  agraphia,  as  paragraphia,  or  literal  agraphia. 
Likewise,  it  Avas  previously  stated  that  a  sharp  distinction  was  to  be 
made  between  volitional  writing,  writing  from  dictation,  and  copying. 
Also,  the  loss  of  the  capacity  to  form  strictly  grammatical  sentences, 
to  make  a  correct  sequence  of  words  (agrammatismus,  akataphasia), 
shows  itself  in  the  writing  also,  or  still  better  than,  in  speaking. 

(c)  Motor  disturbance  of  the  right  upper  extremity  manifests  itself 
in  many  cases  in  a  very  characteristic  way  in  the  handwriting :  the 
lifferent  kinds  of  trembling,  ataxia,  the  different  varieties  of  writers' 
cramp.  It  is  also  worthy  of  note  that  patients  with  paralysis  agitans 
very  frequently  write  naturally  because,  as  is  well  known,  their 
trembling  ceases  when  making  intentional  motions. 

The  value  of  the  handwriting  for  diagnosis  here  consists  chiefly  in 
the  fact  that  we  may  recognize  early  slight  disturbances  (the  contour 
wavy) :  ataxia  manifested  by  the  strokes  going  beyond  bounds, 
especially  by  the  imperfections  of  the  large  letters. 

In  paralytic  dementia  the  writing,  as  well  as  the  speech,  is  ex- 
tremely copious.  This  shows  the  psychical  disturbances  :  delirium 
with  exaltation  or  dementia ;  there  is  agrammatismus,  akataphasia, 
paragraphia,  especially  literal  paragraphia  in  an  extraordinarily  high 
degree;  lastly,  there  may  be  motor  disturbances  of  the  upper  ex- 
tremities, trembling,  ataxia. 

Sense  Organs. 

The  Eye. — In  considering  the  relations  of  the  diseases  of  the  eye 
to  internal  diseases,  those  in  connection  with  the  diseases  of  the 
nervous  system  are  of  very  much  the  greatest  importance. 

We  find  the  eyes,  or  the  function  of  sight,  sympathetically  affected 
in  diseases  of  the  nervous  system  in  a  great  variety  of  ways.     We 

36 


562  SPECIAL  DIAGNOSIS. 

observe  disturbances  which  exhibit  the  more  or  less  direct  results  of 
disease  of  the  nerves  or  of  the  brain.  They  are :  paralyses  (less 
frequently  spasms)  of  the  outer  and  inner  muscles  of  the  eye ;  dis- 
turbances of  the  different  qualities  of  vision  itself,  from  lesion  of  the 
sensory  tract  at  any  point  from  the  optic  nerve  to  the  cortex ;  neuritis 
optica  (choked  disk),  which,  on  the  other  hand,  may  itself  cause  dis- 
turbance of  vision.  Other  conditions,  which  are  coordinate  to  the 
diseases  in  which  they  occur,  oppose  these  conditions.  They  are  of 
extremely  varied  character.  We  mention,  as  examples :  atrophy  of 
the  optic  nerve  in  tabes  dorsalis,  multiple  sclerosis,  embolus  of  the 
central  artery  of  the  retina  with  simultaneous  embolus  of  the  fossa  of 
Sylvius,  syphilitic  iritis  or  retinitis  in  syphilis  of  the  brain. 

Likewise,  the  disturbances  of  the  apparatus  of  vision,  occurring  with 
any  other  internal  diseases,  may  be  either  coordinated  conditions  or 
sequent  phenomena  of  those  diseases.  Of  the  former  category  we 
name  as  examples  :  choroidal  tuberculosis  in  acute  miliary  tuberculosis, 
retinal  hemorrhage  in  general  hemorrhagic  diathesis  (sepsis,  pernicious 
anasmia),  the  various  manifestations  of  syphilis,  etc.  As  a  sequent 
phenomenon  we  have  embolus  of  the  retinal  artery  in  endocarditis 
aortse  or  mitralis,  possibly  cataract  with  diabetes  mellitus,  etc. 

We  give  these  instances  in  order  to  show  in  how  great  a  variety  of 
ways  the  disturbances  of  vision  may  occur  as  symptoms  of  other  dis- 
eases. In  what  follows  we  cannot  classify  the  subject  matter  according 
to  the  points  of  view  mentioned  above.  We  rather  proceed  in  accord- 
ance with  the  course  of  an  examination  of  the  eye. 

1.  Movements  of  the  eye. — As  is  well  known,  these  take  place,  in 
part  at  least,  in  a  very  complicated  way,  by  the  co5rdinate  action  of 
the  muscles  of  the  eye.  Paralysis  or  spasm  of  the  outer  muscles  of 
the  eye  causes  a  defective  motion  of  the  eye  and  disturbs  its  binocular 
motion,  which  we  designate  as  strabismus.  If  the  strabismus  is  due 
to  spasm,  it  is  present  in  all  positions  of  the  eye ;  but  if  dependent 
upon  paralysis,  then  it  has  a  different  relation.  In  slight  paralysis 
(paresis)  of  a  muscle,  strabismus  only  occurs  when  a  motion  of  the  eye 
is  made  which  is  in  a  considerable  degree  dependent  upon  the  co- 
operation of  the  muscle  paralyzed ;  on  the  other  hand,  in  more 
marked  paralysis,  strabismus  may  be  almost  always  present.  It  is 
only  absent  when  the  eyes. are  brought  into  a  position  which  cor- 
responds with  an  especially  marked  relaxation  of  the  paralyzed  muscle. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  563 

In  long-continued  paralysis  of  one  or  more  muscles  of  the  eye,  con- 
tracture of  the  antagonizing  muscles  also  takes  place  ;  in  consequence 
of  which  condition,  strabismus  is  always,  or  almost  always,  present. 
Lateral  strabismus  is  designated  as  divergent  or  convergent,  according 
as  there  is  a  divergence,  or  an  abnormal  convergence,  of  the  axis  of 
vision. 

The  direct  result  of  strabismus  is  double-vision,  or  diplopia.  This 
results  from  the  fact  that,  in  fixing  an  object  whose  image  only  falls 
upon  the  macula  of  the  normal  eye,  it  falls,  in  the  one  whose  muscle 
or  muscles  are  paralyzed,  to  one  side  of  the  maculp^,  and  at  varying 
distances  from  it,  according  to  the  degree  of  the  strabismus  and  the 
distance  of  the  fixed  object  from  the  eye.  In  consequence  of  the 
double  image,  the  determination  of  the  position  of  an  object  in  space, 
and  with  it  the  judgment  of  the  patient  with  reference  to  his  own 
position,  is  disturbed.  Hence,  primarily  there  is  difficulty  in  taking 
hold  of  objects  and  in  walking;  there  is  dizziness  (vertigo  of  the  eye), 
and  this  is  most  marked  when  there  is  diplopia  in  looking  downward 
(paralysis  of  a  rectus  inferior,  of  an  obliquus  superior).  But  after 
long-continued  strabismus  double  vision  disappears,  for  the  patient 
learns  to  voluntarily  shut  out  the  abnormal  eye. 

If  it  happens  to  be  a  case  where  there  is  paralysis  or  spasm  of  the 
muscles  of  both  eyes  which  efi'ect  the  conjugate  motions  of  the  eyes 
(as  the  rectus  internus  of  the  right  and  the  rectus  externus  of  the  left 
eye),  then  we  speak  of  paralysis  of  the  conjugate  muscles  of  the  eyes 
(or  spasm  of  these  muscles) ;  for  the  position  of  the  eyeball  we  employ 
the  designation  conjugate  deviation. 

Paralysis  of  all  or  of  almost  all  of  the  muscles  of  an  eye  results  in 
protrusion  of  the  ball — exophthalmus  paralyticus.  Marked  or  total 
paralysis  of  the  oculomotorius  produces,  beside  the  paralysis  of  the 
eye  (see  below),  also  ptosis  (depression  of  the  upper  lid),  dilatation  of 
the  pupil,  paralysis  of  accommodation  (paralysis  of  the  levator  palp, 
sup,,  of  the  sphincter  of  the  iris,  of  the  muscle  of  accommodation). 

Deviation  of  the  eye  in  which  the  paralysis  or  spasm  is  located  is 
termed  the  primary  deviation.  In  cases  of  paralysis  there  occurs  in 
the  normal  eye  a  so-called  secondary  deviation,  if  we  have  the  patient 
cover  the  normal  eye  and  then  have  him  look  with  it  at  an  object 
which  has  been  fixed  by  the  diseased  one.  (Upon  this  subject,  see 
"works  upon  the  Eye.) 


564  SPECIAL  DIAGNOSIS. 

We  employ  our  own  individual  judgment  in  determining  a  paralysis 
of  the  muscles  of  the  eye,  by  controlling  the  position  of  the  eye  of 
the  patient  while  he  is  looking  at  a  distant  object  and  from  the  accom- 
modation, also,  especially  by  motions  of  the  ball  sideways,  upward 
and  downward ;  moreover,  we  test  the  patient  by  having  him  look 
at  objects  in  different  directions,  and  then  question  him  as  to  double 
vision  and  in  what  relation  the  objects  stands  to  one  another. 

Mode  of  procedure  in  determining  double  vision.  We  hold  up  a 
finger  about  a  metre  from  the  patient,  move  it  up  and  down,  to  the 
right  and  then  to  the  left,  and  hold  the  finger  steadily  in  the  position 
in  which  the  patient  has  a  double  image,  and  then  have  that  position 
described  by  him.  Then  we  suddenly  close  one  eye  :  the  patient  now 
declares  which  image  has  disappeared.  In  this  Avay  we  determine 
to  which  eye  each  one  of  the  double  image  belongs.  Or,  we  take  a 
lighted  candle  as  the  object  of  vision,  and  alternately  cover  an  eye 
with  a  piece  of  colored  glass,  and  then,  of  course,  the  image  presented 
to  this  eye  is  colored.  (For  further  regarding  this  subject  see  works 
upon  the  Eye.) 

In  regard  to  the  significance  of  double  vision,  it  is  first  to  be  stated 
that  when  the  balls  diverge  the  images  are  crossed ;  when  there  is 
abnormal  convergence,  they  are  on  the  same  side  (on  the  side  of  the 
convergence).  All  the  rest  follows  from  what  will  now  be  said  where 
we  collate  the  function  of  individual  muscles  of  the  eye  and  the  effects 
of  paralysis. 

M.  rectus  externus  (N.  abducens),  rolls  the  eye  outward.  Its 
paralysis,  according  to  its  degree,  produces  convergent  strabismus, 
which  is  manifest  either  in  looking  straight  ahead,  or  in  looking  only 
toward  the  side  whose  external  rectus  is  affected.  The  double  vision 
is  also  upon  that  side. 

M.  rectus  internus  (N.  oculomot.),  rolls  the  eye  inward,  antagoniz- 
ing the  preceding.  When  it  is  paralyzed  the  in-rotation  of  the  ball 
is  imperfect ;  there  is  divergent  strabismus,  crossed  double  vision. 

M.  rectus  super.  (N.  oculomot.),  rolls  the  eye  upward  and  at  the 
same  time  a  little  inward.  Rectus  super.  +  obliq.  infer,  together 
cause  upward  motion  of  the  ball.  Paralysis  of  the  rectus  sup.,  limits 
the  motion  upward ;  the  abnormal  eye  stares  downward  and  a  little 
outward :  there  is  double  vision  when  looking  upward ;  the  image 
of  the  paralyzed  eye  is  superimposed  upon  that  of  the  other. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  565 

M.  rectus  inferior  (N.  oculomot.),  rolls  the  ball  downward  and 
slightly  inward ;  acting  with  the  obliq.  sup.,  there  is  simple  down- 
ward motion.  Paralysis  of  the  rectus  infer. :  in  looking  down,  the 
paralyzed  eye  does  not  move,  but  remains  directed  upward  and  a  little 
outward ;  there  is  double  vision,  with  one  image  above  the  other, 
the  lower  being  that  of  the  abnormal  eye. 

M.  obliq.  infer.  (N.  oculomot.),  if  it  is  paralyzed,  in  looking  up- 
ward we  have  the  action  of  the  rectus  sup.  alone :  the  eye  turns  some- 
what inward.  There  is  double  vision  upon  the  same  side,  one  image 
is  above  the  other  or  they  are  side  by  side,  particularly  in  looking 
upward. 

M.  obliq.  super,  (N.  trochlearis),  if  this  is  paralyzed,  then  in  look- 
ing down  the  rectus  inferior  acts  alone,  turning  the  eye  somewhat 
inward.  There  is  double  vision  upon  the  affected  side,  especially  when 
looking  downward. 

Some  of  these  paralyses,  if  they  occur  singly,  can  be  easily  recog- 
nized, and  this  is  especially  true  of  those  of  the  recti.  But  when 
-several  are  combined,  particularly  if  the  obliqui  are  involved,  there  is 
often  the  greatest  difficulty  in  making  out  the  exact  lesion.  A  com- 
bination which  may  occur  frequently  is  a  paralysis  of  all  the  muscles 
supplied  by  the  oculomotorius,  with  which  we  may  then  also  have  the 
internal  muscles  of  the  eye  involving  the  levator  palp.  sup.  With 
this  total  paralysis  of  the  oculomotorius  the  eye  is  rotated  outward 
(the  action  of  the  abducens),  there  is  some  exophthalmia,  the  pupil 
is  dilated  and  remains  so  in  the  presence  of  light,  and  there  is  absence 
of  power  of  accommodation. 

By  nystagmus,  or  oscillation  of  the  eyeball,  we  understand  very 
slight  clonic  jerking  motions  of  the  ball.  They  are  generally  conju- 
gate. If  they  take  place  in  a  horizontal  direction,  then  we  speak  of 
horizontal  nystagmus.  It  is  often  most  distinct  in  fixing  the  eyeball, 
but  particularly  with  marked  rotation  movements  of  the  balls  side- 
ways or  in  a  vertical  direction. 

The  diagnostic  significance  of  paralysis  of  the  muscles  of  the  eye 
varies  very  much  :  paralysis  of  several  muscles  of  only  one  eye  always 
points  with  considerable  probability  to  the  base  of  the  brain,  or  to  the 
orbital  fissure  and  orbit,  and  this  is  particularly  apt  to  be  the  case  if, 
at  the  same  time,  there  is  evidence  of  a  lesion  of  the  optic  nerve  (dis- 
turbance of  vision,  unilateral  choked  disc).     Progressive  paralysis  of 


566  SPECIAL  DIAGNOSIS. 

the  muscles  of  both  eyes,  sometimes  ending  in  total  paralysis  of  these 
muscles,  indicates  a  progressive  nuclear  paralysis  (ophthalmoplegia 
externa).  It  is  difficult  to  estimate  the  symptomatic  value  with  refer- 
ence to  the  topical  diagnosis  of  conjugate  deviation.  When  it  is 
present  we  should  always  first  think  of  the  possibility  of  a  lesion  of 
the  posterior  corpus  quadrigeminum  or  its  neighborhood ;  but  aside 
from  this,  conjugate  deviation  occurs  with  all  kinds  of  local  disease 
of  the  brain,  especially  if  recent.  Hence,  if  the  deviation  is  due  to 
paralysis,  we  infer  that  the  line  of  vision  is  toward  the  same  side, 
but  if  it  is  a  conjugate  spasm,  the  line  of  vision  is  toward  the  opposite 
side.  In  the  latter  case  the  head  is  very  often  drawn  to  that  side. 
Paralysis  of  the  oculomotorius  of  one  side  and  of  the  extremities  of 
the  opposite  side  (crossed  paralysis)  points  with  great  certainty  to  a 
lesion  of  the  crus  cerebri,  and  this  corresponds  with  paralysis  of  the 
third  nerve.  We  can  immediately  understand  this  fact  if  we  recollect 
that  the  N.  oculomotorius  dexter  passes  to  the  right  crus  cerebri  at  its 
base — that  is,  it  passes  alongside  of  the  pyramidal  tract  belonging  to 
the  left  side  of  the  body. 

2.  The  pupils. — We  do  not  concern  ourselves  with  those  changes 
of  the  pupil  which  belong  wholly  in  the  province  of  diseases  of  the 
eye  (especially  in  connection  with  iritis). 

We  are  to  consider  the  size,  or  the  changes  in  the  size,  which 
result  from  certain  circumstances.  When  the  iris  is  normal,  the 
size  is  regulated  by  the  action  of  two  antagonizing  muscles  :  the 
sphincter  pupillae  (N.  oculomotorius)  and  the  dilator  pupillse  (N.  sym- 
patheticus). 

[a)  The  size  of  the  pupil.  Contracted  pupil,  mi/osis,  occurs  in 
health  during  sleep,  likewise  in  old  age.  Otherwise  myosis  is 
always  a  sign  which  must  awaken  suspicion,  and  indeed  is  especially 
frequent  in  tabes  dorsalis  (see  below,  Reflex  rigid  pupil) ;  and,  also, 
although  more  rarely,  in  progressive  paralysis.  The  degree  of  the 
illumination  also  has  a  marked  effect  upon  the  size  of  the  pupil  (if  from 
reflex  action  it  is  not  rigid,  see  below  under  c).  Hence,  it  is  to  be 
examined  under  moderate  illumination.  Dilatation  of  the  pupil, 
mydriasis.,  occurs  with  marked  disturbances  of  consciousness,  severe 
pain  (see  below  under  c),  with  atrophy  of  the  optic  nerve,  paralysis  of 
the  M.  oculomotorius ;  lastly,  sometimes  with  tabes  and  progressive 
paralysis. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  5tj7 

Effect  of  poisons.  Atropine,  duboisin,  cocaine,  dilate  the  pupil ; 
eserine,  pilocarpin,  morphia,  contract  it.  These  eiFects  upon  the  pupil 
are,  in  connection  with  other  symptoms,  employed  for  diagnosis  in 
cases  of  poisoning  with  any  of  these  substances. 

(b)  Inequality  of  the  pupils  sometimes  occurs  with  persons  in 
health,  also  in  people  Avith  unequal  refraction  in  the  two  eyes  (with 
myopia :  mydriasis ;  in  hypermetropia :  myosis) ;  but,  otherwise, 
inequality  of  the  pupils  is  a  suspicious  symptom.  It  occurs  in  uni- 
lateral aifections  of  the  brain  of  all  kinds  (thus,  especially  with 
lisematoma  of  the  dura),  with  unilateral  paralysis  of  the  oculomotorius, 
of  the  opticus  (dilatation),  and  in  tabes ;  besides,  it  frequently  occurs 
in  attacks  of  migraine  (irritation,  paralysis  of  the  sympathetic  of  the 
aifected  side). 

(e)  Reflex  changes  in  the  size  of  the  pupil.  The  pupil  contracts 
in  the  presence  of  light  from  the  contraction  of  the  sphincter  (the 
reflex  arc  [composed  as  follows]  :  (a)  the  optic  nerve ;  (b)  optic  tract ; 
(c)  probably  the  anterior  corpus  quadrigeminum ;  {d)  oculomotorius). 
The  test  is  made  either  in  a  light  room  by  covering  the  eye  with  the 
hand  and  then  suddenly  withdrawing  it,  or  in  a  room  with  a  dim  light 
by  quickly  going  to  the  light  (more  certain).  In  either  case  the 
patient  must  not  employ  any  accommodation,  hence  must  look  at  a 
distant  object  (see  below,  converging  motion).  It  is  best  to  test  each 
eye  singly  by  alternately  closing  one.  Sometimes  there  is  an  indica- 
tion for  testing  the  crossed  ("  consensual  ")  reaction  :  we  observe  the 
changes  in  the  pupil  of  the  right  eye,  while  we  vary  the  light  which 
enters  the  left,  and  vice  versa.  (Regarding  hemiopic  pupillary  reaction, 
see  below.)     In  old  age  the  reaction  of  light  is  physiologically  slow. 

Pain,  as  painful  irritation  of  the  skin  (pinching,  Faradic  brush), 
dilates  the  pupil  through  the  action  of  the  dilator.  The  reaction  is 
slower  and  less  marked  than  from  light. 

Absence  of  reaction  is  the  term  used  for  "reflex  rigid  pupil "  (Erb), 
both  "  to  light  "  and  "  to  pain.''  This  absence  of  both  reactions  often 
goes  hand-in-hand,  especially  in  tabes,  where  Erb  in  84  cases  found 
59  instances  (=  81.5  per  cent.)  of  absolutely  rigid  pupils,  or  (moi-e 
rarely)  very  feeble  reaction.  At  the  same  time  there  was  always 
reflex  rigidity  with  reference  to  pain ;  and,  further,  in  37  cases  (=  52 
per  cent.)  simultaneous  myosis.  Reflex  rigidity  is  less  frequent  in 
progressive  paralysis ;  but  there  rai-cly  over  occurs  any  other  abnor- 


538  SPECIAL  DIAGNOSIS. 

mality  of  the  pupils  (myosis,  mydriasis,  inequality,  slow  reaction  of 
rigidity)  in  this  condition. 

The  reaction  of  light  also  fails  in  atrophy  of  the  optic  nerve,  and 
in  complete  paralysis  of  the  oculomotorius.  But  it  does  not  fail  in 
central  blindness,  hence  not  in  cortical  hemianopsia.  Moreover,  when 
testing  in  this  case,  the  light  from  the  side  where  the  field  of  vision  is 
defective  must  be  brought  nearer,  so  that  it  may  only  fall  upon  the 
half  of  the  retina  which  is  cut  oif  from  the  centre  (see  p.  569). 
Reaction  of  light  takes  place  in  the  diseased  eye  in  unilateral  optic 
atrophy  when  the  normal  eye  is  illuminated ;  on  the  other  hand, 
reaction  of  light  is  not  retained  in  the  diseased  eye  in  unilateral  com- 
plete paralysis  of  the  oculomotorius,  as  is  evident  from  the  course  of 
the  reflex  arc. 

{d)  Contraction  of  the  pupil  in  convergence  of  the  eyes,  or  from 
accommodation,  may  not  take  place  in  paralysis  of  accommodation 
(this  most  frequently  after  acute  diseases,  particularly  diphtheria), 
but  it  may  also  be  retained.  This  contraction  of  the  pupils  during 
accommodation  has  its  chief  diasrnostic  significance  in  the  fact  that  it 
must  be  avoided  when  testing  for  the  reaction  to  light  or  pain — that 
is,  it  is  generally  retained  with  reflex  rigidity  of  the  pupils. 

3.  Testing  for  the  central  sharpness  of  vision,  the  color-sense,  and 
the  field  ofvisioyi. 

(a)  We  test  the  shai'pness  of  vision  by  means  of  Snellen's  plates, 
which  contain  test-letters  of  diff"erent  sizes,  the  number  of  which  is 
represented  by  the  distance  in  metres  at  which  a  normal  eye  can  read 
the  type.  After  correcting  any  possible  anomaly  of  refraction  in 
either  eye,  they  are  placed  at  a  distance  at  which  it  can  read  the  test- 
letter  X.  The  sharpness  of  vision  is  expressed  by  a  fraction  whose 
denominator  is  the  number  on  the  plate,  and  whose  numerator  is  the 
distance  at  which  it  can  be  read.  According  to  the  above,  in  normal 
vision  the  denominator  and  numerator  must  be  alike ;  the  fraction 
then  is  always  equal  to  1  (f,  f,  etc.) ;  instead  of  this  [the  sharpness 
of  vision  represented  by]  SV.  =  f ,  in  case  the  eye  is  diseased  we 
have  SV.  =  f,  etc.     (For  particulars,  see  text-books  on  the  Eye.) 

As  a  matter  of  course,  if  we  discover  a  diminution  in  the  sharpness 
of  vision,  before  we  conclude  that  it  is  due  to  a  disease  of  the  nervous 
system  we  must  exclude  any  disease  of  the  refractive  apparatus. 
(Here,  also,  the  reader  is  referred  to  special  works  upon  the  Eye.) 


EXAMINATION  OF  THE  NERVOUS  SFSTEM.  539 

(h)  Testing  the  field  of  vision,  FV.,  tlie  "peripheral  sight."  The 
most  exact  way  to  do  this  is  to  employ  a  perimeter.  A  substitute  for 
this  expensive  instrument,  which  can  be  recommended  to  one  who  is 
not  a  specialist,  is  the  field-of-vision  chart,  which  has  six  straight 
lines  intersecting  each  other  at  a  point  making  angles  of  45  degrees. 
Starting  from  the  point  of  intersection,  these  lines  are  divided  into 
centimetres.  At  the  point  of  intersection  a  rod  of  definite  length 
stands  perpendicular  to  the  chart  (it  is  screwed  into  the  chart)  ;  upon 
this  upright  is  a  hoop  into  which  the  person  to  be  examined  places 
his  head.  It  is  used  in  the  same  way  as  a  perimeter.  The  normal 
size  of  the  field  of  vision  for  three  or  four  healthy  persons,  with  a 
definite  length  of  the  upright,  is  placed  upon  the  chart,  (It  will  be 
shown  that  on  the  outer  side  the  field  of  vision  is  endless,  because 
the  angle  is  less  than  90  degrees  to  the  direction  of  the  line  of 
sight — but  of  this  no  account  is  taken.)  The  pathological  result  is 
drawn  upon  a  diagram  which  represents  the  chart  and  the  normal 
field  of  vision  on  a  smaller  scale. 

We  recognize  very  decided  disturbances  by  steadily  holding  a  finger 
about  a  half  metre  from  and  in  front  of  the  eye,  and  then  moving  the 
other  hand,  or  a  light  held  by  it,  in  every  direction  in  the  field  of 
vision.  Of  course,  in  this  case,  as  in  all  others,  we  are  to  test  each 
eye  singly.  The  great  difficulty  is  in  having  the  patient  hold  the  eye 
fixed  immovably. 

Concentric  narrowing  of  the  field  of  vision  rarely  occurs  in  organic 
diseases  of  the  brain.  It  oftener  occurs  with  multiple  sclerosis, 
usually  from  atrophy  of  the  optic  nerve  (see  below),  more  frequently 
in  neuroses ;  and  it  is  an  especially  important  symptom  in  hysteria, 
*'  traumatic  hysteria,"  but  also  in  "  railroad  neurosis,"  which  is  closely 
related  to  this.  With  atrophy  of  the  optic  nerve  there  likewise  occurs 
narrowing  of  the  field  of  vision,  which  is  concentric,  more  rarely 
in  the  form  of  a  sector.  Central  scotoma  occurs  particularly  in 
alcohol-  and  tobacco-amblyopia. 

The  result  of  semi-decussation  of  the  optic  in  the  chiasm  is  the 
peculiar  symptom  known  as  homonymous  hemianopsia — a  defect  in 
the  field  of  vision,  involving  about  half  of  it,  upon  the  same  side  of  the 
body  in  both  eyes.  Fig,  168  explains  this  condition:  a  complete 
interruption  of  the  optic  tract  or  of  the  path  centrally  from  it,  or, 
lastly,  a  total  destruction  of  the  sight- centre  in  the  cortex  of  the 


570 


SPECIAL  DIAGNOSIS. 


occipital  lobe,  from  which  there  must  result  hemianopsia ;  and,  too, 
the  centripetal  conduction  of  the  half  of  the  retina  corresponding  to 
the  side  of  the  lesion  will  be  interrupted,  consequently  the  half  of  the 
field  of  vision  opposite  the  lesion  will  be  defective.  Thus,  homonymous 
hemianopsia  indicates  a  lesion  which  affects  the  tract  of  sight  between 


Fig.  If 


^^^^^ 


Schematic  drawing  for  explaining  the  relation  of  the  eyes  to  Tision,  and  representing 
hemianopsia.  The  direction  of  vision  of  the  two  eyes  BR  is  very  nearly  parallel  (the 
eyes  being  fixed  upon  a  distant  object),  ikf,  macula  lutea;  C/i,  chiasm;  Rr,  Ml,  r\gh.\, 
and  left  cortical  field  of  sight  (occipital  cortex).  ITotice  a  kind  of  semi-decussation  in 
the  chiasm,  the  division  of  the  fibres  in  the  retinae,  and  the  character  of  the  images  as 
they  appear  in  the  cortex.  S,  a  local  disease  behind  the  chiasm ;  it  causes  hemianopsia. 
The  portion  of  the  fieldof  vision  which  disappears,  and  the  cortical  field  which  does  not 
perceive  the  object,  are  hatched.  The  corresponding  tracts  are  represented  by  a  wavy 
line. 

the  chiasm  and  the  cortex.  Without  doubt,  this  tract  also  passes 
through  the  posterior  portion  of  the  posterior  crus  of  the  inner  capsule, 
and  with  equal  certainty  is  in  relation  with  the  anterior  corpus  quadri- 
geminum  of  the  affected  side,  for  from  here  also  hemianopsia  may  arise, 
or,  when  there  is  lesion  of  the  corpora  quadrigemina  of  both  sides, 
there  is  blindness.     Lesion  of  a  tract  as  far  as  to  the  affected  corpus 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  57 1 

quadrigeminum  causes  hemianopsic  rigidity  of  pupil  with  respect  to 
light  (see  above,  Hemianoptic  reaction  of  the  pupils — Wernicke). 

Hemianopsia  is  sometimes  made  manifest  by  the  patient  not  notic- 
ing Avhen  some  one  comes  to  his  bed  from  that  side  ;  by  his  not  being 
startled  when  a  light  is  quickly  brought  near  him  from  the  affected 
side ;  or,  in  writing,  he  does  not  see  what  he  has  written  upon  one 
side  of  a  sheet  of  paper,  etc. 

A  bilateral  dropping  out  of  the  nasal  half  of  the  retina,  with  bilat- 
eral temporal  (hence,  not  homonymous)  hemianopsia,  may  be  caused 
by  a  tumor  which  is  situated  close  in  front  of  or  behind  the  chiasm. 
In  this  case  the  two  eyes  in  some  degree  may  compensate,  by  mutual 
action,  for  the  defect,  though,  of  course,  very  imperfectly — for  binocu- 
lar sight  is  no  longer  possible.  There  occur  other  difficulties  whose 
description  does  not  belong  here. 

Subjective  sensations  of  vision  occur  in  severe  diseases  of  the  eyes 
of  all  kinds,  but  especially  in  anaemia  (flimmering),  with  nervous  sub- 
jects. Temporary  partial  amaurosis  has  great  significance :  a  strong 
shining,  generally  pronounced  unilateral  subjective  sensation  of  light, 
which,  in  some  of  the  cases,  is  markedly  present  in  migraine  {migraine 
ophthalmique)^  sometimes,  during  the  attack,  passing  into  hemianopsia. 

(c)  The  color-sense.  The  central  perception  of  color  is  tested  by 
means  of  skeins  of  woollen  yarns  of  as  pure  colors  as  it  is  possible 
to  obtain.  The  color-sense  within  the  limits  of  the  field  of  vision — in 
other  words,  the  size  of  the  field  of  vision  for  the  individual  colors — is 
ascertained  in  the  same  way  as  that  of  pure  white  (see  above).  It  is 
not  without  importance  (see  text-books  upon  diseases  of  the  Eye). 

[d)  The  results  of  the  ophthalmoscopic  examination  which  are  here 
of  interest  to  us  will  be  found  in  the  Appendix. 

The  diasrnostic  value  of  the  electrical  reaction  of  the  retina  cannot 
be  determined,  hence  we  pass  it  over  here. 

Hearing. — Functional  test.  We  ascertain  the  distance  at  which  a 
whisper  can  be  heard  (a  healthy  person  in  a  closed  room  can  catch  it 
at  a  distance  of  about  twenty-five  metres).  We  also  employ  the  tick 
of  a  watch,  which  has  previously  been  tested  upon  healthy  persons,  to 
ascertain  the  distance  at  which  it  can  be  heard.  As  a  matter  of  course 
each  ear  is  to  be  examined  separately,  and  the  ear  not  being  examined 
is  to  be  closed.  To  this  also  extends  the  testing  of  the  behavior  of 
the  conductivity  of  the  bones :    a  normal  person  does  not  at  all  or 


572  SPECIAL  DIAGNOSIS. 

only  barely  hears  a  watch  held  near  to  the  closed  ear,  but  hears  it 
distinctly  when  it  is  brought  in  contact  with  the  skull  in  the  neigh- 
borhood of  the  ear.  Persons  with  disease  of  the  outer  ear-passage 
and  of  the  middle  ear  are  in  the  same  condition  as  those  with  normal 
ears  when  more  or  less  completely  closed :  at  a  distance  they  hear 
poorly  or  not  at  all,  but  by  the  conduction  of  the  bones  they  can  hear 
excellently  well.  On  the  other  hand,  when  the  acoustic  nerve  or  its 
terminations  in  the  tympanic  cavity  are  diseased  (nervous  deafness), 
hearing  at  a  distance  and  through  the  bones  are  both  alike  diminished. 

The  examination  with  the  ear-mirror  cannot  be  described  here.  It 
naturally  comes  into  consideration  for  the  differential  diagnosis  of 
nervous  deafness  and  of  aifections  of  the  middle  ear  or  of  the  external 
ear  passages.  (Regarding  this  and  its  detailed  use,  see  the  text-books 
upon  diseases  of  the  Ear.)  We  call  especial  attention,  from  the  funda- 
mental scientific  points  of  view,  to  the  important  electrical  examination 
of  the  acoustic  nerve  (Brenner) ;  it  is  true  that,  in  its  diagnostic  rela- 
tions, it  has  no  independent  significance. 

Apart  from  the  special  aural  point  of  view,  the  determination  of  a 
disease  of  the  ear  or  of  the  sense  of  hearing  is  of  importance  for  vari- 
ous reasons  :  (a)  for  recognizing  constitutional  afi"ections  (caries  of  the 
petrous  bone  in  scrofula,  tuberculosis,  middle-ear  catarrh  in  syphilis ; 
see  p.  286) ;  (h)  for  recognizing  any  other  local  disease  of  the  cranium, 
or  within  the  cranium  (at  its  base),  or  of  the  brain,  which  injures  the 
acoustic  nerve  or  the  central  conduction  of  hearing ;  lastly,  with  ref- 
erence to  further  resulting  phenomena  of  a  disease  of  the  ear  or  the 
petrous  bone,  if  they  exist :  purulent  (sometimes,  also,  tuberculous) 
meningitis,  abscess  of  the  brain,  and  facial  paralysis. 

It  is  further  to  be  mentioned  that,  on  the  other  hand,  in  a  normal 
condition  of  the  hearing  apparatus  a  functional  disturbance  may  be 
caused  by  a  rheumatic  facial  paralysis,  if  it  is  located  high  up : 
from  paralysis  of  the  stapedius  muscle,  supplied  by  the  facial,  and 
predominant  development  of  the  tensor  tympani,  there  may  arise  a 
morbid  acuteness  of  hearing,  especially  for  deep  tones. 

Subjective  sensibility  of  hearing  (tingling,  ringing,  buzzing,  roaring 
in  the  ear,  etc.)  occurs  in  anaemia,  nervousness ;  further,  in  diseases 
of  this  organ  of  any  kind ;  but,  lastly,  also  in  palpable  nervous  dis- 
eases.    The  latter  are  then  generally  affections  of  the  acoustic  nerve, 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  573 

as  compression  or  neuritis,  or  of  its  terminations  in  the  labyrinth. 
Subjective  auditory  sensations,  as  signs  of  disease  of  the  acoustic 
nucleus  of  the  oblongata,  or  of  the  auditory  tract  in  its  central  course, 
or  of  the  auditory  centre  of  the  cortex  in  the  temporal  lobe,  are  very 
rare,  if  not  unreliable.  It  is  very  worthy  of  note  that  tinnitus  aurium 
may  sometimes  introduce  an  attack  of  migraine,  apoplexy,  or,  as  an 
aura,  an  epileptic  attack. 

Tinnitus  aurium  may  occasionally  be  combined  with  dizziness 
(nervus  vestibularis) ;  this  is  much  the  most  pronounced  in  Meniere's 
disease.  Marked  ringing  in  the  ears  ma}^  become  the  source  of 
psychical  disturbance. 

In  order  to  make  a  diagnosis  of  word-deafness,  or  of  sensory  aphasia, 
it  is,  of  course,  necessary,  as  a  preliminary  condition,  to  determine 
whether  the  hearing  is  good. 

Lastly,  attention  must  be  especially  called  to  the  fact  that  a  uni- 
lateral disturbance  of  the  hearing  may  have  entirely  escaped  the 
attention  of  the  patient. 

Smell. —  Testing  its  function.  For  this  purpose  we  may  employ 
camphor,  petroleum,  perfumed  spirit,  and,  as  disgusting  material, 
asafoetida  ;  but  not  ammonia  or  acetic  acid,  because  even  a  very  slight 
amount  of  the  vapor  of  these  substances  may  irritate  the  trigeminus. 
We  first  test  one  side  and  then  the  other.  We  do  not  here  describe 
the  examination  of  the  nose  with  the  nasal  speculum. 

Anosmia  [loss  of  the  sense  of  smell]  of  neuropathic  origin  is  not 
very  frequent.  It  occurs  in  processes  in  the  anterior  cranial  fossa  and 
the  anterior  portion  of  the  brain  which  lead  to  compression  of  the 
olfactory,  as  from  tumors,  meningitis,  hydrocephalus;  and  here  it  is 
also  due  to  compression  of  the  olfactory.  Unilateral  anosmia  has  been 
observed  as  an  associated  phenomenon  of  total  hemiansesthesia  in  lesion 
of  the  posterior  portion  of  the  internal  capsule — of  course,  on  the  side 
opposite  to  that  diseased.  But  in  exactly  the  same  way  we  may  have 
unilateral  anosmia  with  hysterical  hemiansesthesia. 

It  is  rare  to  have  anosmia  from  lesion  of  the  nerves  passing  off 
from  the  bulb  in  the  ethmoid  bone,  when  this  bone  is  fractured.  But 
it  is  always  to  be  remembered  that  the  most  frequent  cause  of  loss 
or  diminution  of  the  sense  of  smell  is  disease  of  the  nasal  mucous 
membrane.     It  is  further  to  be  noticed  that  in  old  age  anosmia  some- 


574  SPECIAL  DIAGNOSIS. 

times  occurs  without  any  notable  pathological  cause  (atrophy  of  the 
olfactory). 

In  very  isolated  cases  the  disturbance  is  to  be  referred  to  paralysis 
of  the  trigeminus ;  that  is,  to  the  dryness  of  the  nasal  mucous  mem- 
brane due  to  the  paralysis. 

Hyperosmia  and  osmic  parsesthesia  (parosmia)  occur  in  hysteria  and 
insanity,  and  as  an  aura  in  genuine  epilepsy. 

Regarding  the  significance  of  the  nose  as  a  point  of  departure  in 
disease  within  the  cranium,  compare  further,  pp.  358-9. 

Taste.  —  Testing  its  function.  We  test  it  for  the  recognition  of 
salt,  sugar,  vinegar,  and  quinine.  We  also  make  a  test  by  retaining 
the  same  order  of  succession  of  all  these  substances  when  suitably 
diluted.  Then  follows  the  testing  of  a  circumscribed  portion  of  the 
tongue,  as  first  one  and  then  the  other  half  of  the  tongue,  then  the 
anterior  two-thirds  as  compared  with  the  posterior  one- third,  because 
the  former  portion  is  supplied  by  the  chorda,  the  latter  by  the  glosso- 
pharyngeus.  For  this  purpose  we  wipe  the  tongue  somewhat  dry, 
apply  to  it  a  very  little  of  the  [test]  fluid  with  a  glass  rod,  remove  any 
surplus  and  have  the  tongue  simply  drawn  back,  but  without  any 
further  motion.  Although  this  method  is  somewhat  doubtful,  since  a 
portion  of  the  hard  and  soft  palate,  which  cannot  be  exactly  defined, 
also  possesses  the  sense  of  taste,  yet  it  seems  practicable,  as  follows 
from  its  positive  results  in  certain  cases  of  facial  paralysis.  The 
more  exact  method  of  not  drawing  the  tongue  back  into  the  m®uth 
after  the  test  substance  has  been  put  upon  it,  thus  to  eliminate  the 
assistance  of  the  palate,  has  the  disadvantage  that  then  even  persons 
in  health  can  only  imperfectly  taste. 

Ageusis  [loss  of  the  sense  of  taste]  on  one  side  of  the  tongue  is 
observed  with  total  hemianaesthesia.  Unilateral  ageusis  of  the  anterior 
portion  of  the  tongue  occurs  also  from  peripheral  chordal  paralysis, 
and  this  is  the  case  whether  it  involves  injury  of  the  branch  of  the 
trigeminus  as  far  as  the  Gasserian  ganglion,  or  of  the  second  branch 
from  there  to  the  spheno-palatine  ganglion,  or  of  the  facial  between 
the  geniculate  ganglion  and  the  point  where  the  chorda  is  given  off, 
or  of  the  commisural  portion  between  the  fifth  and  seventh  nerves,  the 
N.  petrosus  superf.  major.     Total  ageusis  points  to  hysteria. 

Moreover,  the  fineness  of  the  taste,  as  well  as  of  smell,  varies  much 
with  the  individual. 


examination  of  the  nervous  system.  575 

Disturbances  op  the  Vegetative  System  ix  Nervous 

Diseases. 

We  must  here  limit  ourselves  to  a  brief  enumeration  of  the  most 
important  points. 

1.    G-eneral  Phenomena, 

The  apoplectic  habit  (short,  thick  neck,  red  face,  full  chest,  abun- 
dant layer  of  fat)  decidedly  predisposes  to  hemorrhage  of  the  brain, 
but  this  also  occurs  very  frequently  even  in  very  lean  and  anaemic 
subjects.  In  other  respects  the  general  habit  does  not  predispose 
individuals  to  diseases  of  the  nervous  system. 

Nervous  diseases  affect  the  nutrition  in  a  great  variety  of  ways, 
sometimes,  for  a  long  time,  not  at  all,  and  again  very  decidedly.  It 
depends  chiefly  upon  the  accompanying  vegetative  disturbances  :  fever, 
decubitus  (which  see)  and  the  various  disturbances  of  individual 
internal  organs  to  be  mentioned. 

A  tuberculous  nature  of  a  local  disease  of  the  brain,  or  of  a  menin- 
gitis may  be  suspected  (aside  from  possible  tuberculosis  of  the  lungs, 
scrofula,  hectic  fever)  when  the  nutrition  is  decidedly  poor.  The  same 
thing  is  true  with  respect  to  carcinoma. 

Fever  occurs  in  diseases  of  the  nervous  system  :  (a)  if  the  disease 
itself  is  of  an  inflammatory  or  infectious  nature ;  {h)  if  it  causes 
vegetative  disturbances,  as  decubitus,  cystitis,  etc.,  which  in  turn 
give  rise  to  fever ;  {c)  in  many  cases  where  the  elevation  of  the  tem- 
perature is  supposed  to  be  of  a  neurotic  character :  in  progressive 
paralysis,  in  injury  of  the  cervical  spinal  cord,  which  is  not  fatal 
(here,  according  to  Naunyn  and  Quincke,  the  increase  in  the  produc- 
tion of  heat  rises  to  44  C.  [=112°  F.]),  in  tetanus,  in  severe  epileptic 
attacks. 

Diminution  of  temperature  is  likewise  seen  in  progressive  paralysis, 
and  with  injuries  of  the  cervical  spinal  cord. 

2.  Disturbances  of  the  Respiratory  Apparatus. 

Nose.  Certain  affections  of  the  nose  (nasal  polypi,  enlargement  of 
the  turbinated  bones,  chronic  catarrh)  stand  in  a  peculiar,  often  causal 
relation  to  various  neuroses,  especially  to  bronchial  asthma,  to  nervous 
affections  of  the  heart.     The  nose,  through  the  ethmoid  bone,  may  be 


57G  SPECIAL  DIAGNOSIS. 

the  gate  of  entrance  for  meningitis  or  abscess  of  the  brain  ;  also,  it  is 
to  be  mentioned  that  the  nose  comes  especially  under  consideration  in 
the  diagnosis  of  syphilis. 

Larynx.  The  larynx  may  be  paralyzed.  When  there  is  anaes- 
thesia of  the  larynx  we  investigate  its  nerves  and  their  centres  in  the 
bulb ;  further,  hysteria  sometimes  comes  into  consideration.  See 
some  additional  remarks  regarding  the  larynx  in  the  Appendix.  We 
have  a  nervous  cough  from  simple  nervousness,  also  in  hysteria. 
Laryngeal  spasm  is  an  attack  of  nervous  cough,  which  may  occur  in 
decidedly  varying  severity  from  slight  irritative  cough  to  attacks 
resembling  whooping-cough  of  the  severest  character.  It  is  produced 
by  irritation  of  the  vagus  by  tumors  of  the  bronchial  glands,  or  it 
occurs  in  tabes  and  hysteria. 

Dyspnoea :  see  what  was  said  regarding  asthma  in  connection  with 
the  nose.  It  occurs  also  in  uraemia,  and  is  sometimes  the  most  promi- 
nent symptom  in  chronic  uraemia,  and  in  diabetes.  Lastly,  dyspnoea 
is  caused  by  functional  and  true  paralysis  of  the  respiratory  muscles. 
With  the  latter  we  take  into  consideration  the  tracts  of  the  nerves, 
the  nerve  centres,  especially  the  respiratory  centre  in  the  bulb.  Dys- 
pnoea is  caused  also  by  tonic  and  rapidly  recurring  clonic  spasms  of 
these  muscles.  In  hysteria  there  is  great  disturbance  of  the  breath- 
ing :  extremely  rapid  superficial,  or  labored,  deep,  panting  breathing, 
and  temporary  fixation  of  the  diaphragm.  (Regarding  Cheyne- Stokes 
phenomenon,  see  p.  92.) 

The  condition  of  the  lungs  and  the  character  of  the  sputum  are 
chiefly  regarded  from  two  points  of  view :  the  determination  of  a 
tuberculosis ;  and,  because  a  connection  between  fetid  bronchitis, 
abscess  or  gangrene  of  the  lungs,  emphysema,  and  purulent  menin- 
gitis and  abscess  of  the  brain  has  recently  been  recognized. 

3.  Disturbances  in  the  Circulatory  Apparatus. 

Heart.  This  has  most  important  relations  to  hemorrhages  and  em- 
bolic softening  of  the  brain:  hypertrophy  of  the  left  ventricle  favors 
the  occurrence  of  hemorrhage  (contracted  kidney)  and  valvular  endo- 
carditis. In  case  of  weak  heart,  thrombi  existing  within  the  heart 
(the  auricular  appendix),  may  cause  emboli.  Atheroma  of  the  vessels 
likewise  may  cause  hemorrhage,  emboli,  and  local  thrombosis  of  the 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  577 

vessels  of  the  brain.  But  often  aneurism  of  the  minute  arteries  of  the 
brain  causes  hemorrhages  without  there  being  any  atheroma  of  the 
vessels  of  the  body.  Whenever  there  is  loss  of  consciousness,  but  espe- 
cially in  every  case  of  apoplexy,  and  of  paralysis,  which  is  to  be  referred 
to  the  brain,  the  heart  and  vessels  are  to  be  most  carefully  examined. 

Palpitation  and  pain  (angina  pectoris)  occur  in  organic  disease  of 
the  heart,  in  simple  nervousness  (heart  neuroses),  in  hysteria,  in  Base- 
dow's disease,  and  in  nicotine  poisoning.  Hence  these  phenomena 
may  have  great  diversity  of  significance. 

Much  has  already  been  said  (p.  237if.)  regarding  the  anomalies  of 
frequency  of  the  pulse.  Temporary,  seldom  continuous,  quickening 
of  the  pulse  occurs  in  neuroses ;  but,  besides,  paralysis  of  the  vagus 
or  the  vagus  nucleus  (neuritis,  bulbar  paralysis)  quickens  the  pulse, 
often,  also,  causes  a  gallop-rhythm  (see  p.  220). 

The  vasomotor  disturbances  are  extremely  manifold  and  interesting, 
but,  according  to  our  present  knowledge,  are  seldom  of  diagnostic  im- 
portance. There  must  be  mentioned  the  unilateral  paleness  or  redness 
of  the  head  in  many  cases  of  migraine  (hemicrania,  sympathetica 
spastica  and  sympathetica  paralytica) ;  unilateral  paleness  in  hysteri- 
cal hemiansesthesia.  We  observe  cyanosis,  coldness,  oedema,  especially 
frequently  in  cerebral,  sometimes  also  in  spinal  (poliomyelitis  acut.)  and 
in  peripheral  paralyses,  and  in  hysteria.  Sensations  of  heat  of  the 
skin  in  Basedow's  disease — perhaps,  also,  in  paralysis  agitans — are  to. 
be  referred  to  vasomotor  influences.  Regarding  the  secretion  of  per- 
spiration, see  p.  36f. 

Local  asphyxia  (cyanosis,  coldness)  and  spontaneous  symmetrical 
gangrene  is  observed  in  general  neuroses,  peripheral  neuritis,  but  also 
in  acute  infectious  diseases,  diabetes,  and  ergotism. 

4.  Disturbances  of  the  Digestive  Apparatus. 

Very  much  has  already  been  said  upon  this  point,  hence  reference 
is  made  to  p.  284fF. 

Anaesthesia  of  the  pharynx  may,  exceptionally,  be  evidence  of  a 
palpable  disease ;  it  is  a  much  more  frequent  and  important  symptom 
of  hysteria. 

Increase  in  the  secretion  of  saliva  occurs  in  psychoses,  idiotism,  also 
in  bulbar  paralysis ;  in  all  three  cases — in  the  first  from  inattention, 

37 


578  SPECIAL  DIAGNOSIS. 

in  the  latter  from  simultaneous  paralysis  of  the  lips,  tongue,  and  mus- 
cles of  deglutition — the  secretion  sometimes  runs  out  of  the  mouth. 
But,  for  the  same  reason,  in  bulbar  paralysis  the  secretion  escapes 
from  the  mouth,  although  it  is  not  increased  in  amount.  Diminished 
secretion  of  saliva  is  seen  chiefly  in  facial  paralysis  (secretory  fibres  in 
the  chorda  tympani). 

We  are  also  to  bear  in  mind  the  nervous  dyspepsias,  Avhich  may  be 
divided  into  psychical  disturbances,  as  dyspeptic  difiiculties  with  per- 
fectly normal  digestion,  and  nervous  disturbances  of  secretion  or  of 
the  motor  function  of  the  stomach.  The  diagnosis  is  to  be  determined 
by  an  examination  of  the  contents  of  the  stomach. 

As  was  previously  mentioned,  vomiting  takes  place  in  all  kinds  of 
disease  of  the  brain,  especially  in  those  that  develop  rapidly ;  further, 
very  especially  in  the  course  of  diseases  of  the  cerebellum.  It  is  also 
to  be  mentioned  that  there  is  vomiting  with  migraine  and  hysteria. 
Gastric  crises  are  attacks  of  very  severe,  often  widely-radiating 
cardialgia,  associated  with  vomiting  (hyperacidity) ;  they  are  a  pecu- 
liarity of  tabes,  and  not  infrequently  they  are  for  a  long  time  misun- 
derstood. Intestinal  crises  (attacks  of  colic),  and  those  involving  the 
rectum  (severe  tenesmus),  are  rare  occurrences  in  tabes. 

With  a  number  of  nervous  disturbances,  especially  in  children,  we 
must  think  of  intestinal  parasites.  They  may  cause  nervous  agitation, 
marked  nervousness,  attacks  like  migraine,  and  spasms.  It  is  not 
unimportant,  although  very  infrequent,  that  the  taenia  solium  may 
infect  the  subject  who  has  it  with  cysticercus  [cellulosae]  :  thus,  some- 
times, cysticerci  may  develop  in  the  brain,  in  the  eye. 

Habitual  constipation  is  especially  frequent  in  all  kinds  of  diseases 
of  the  spinal  cord.  Marked  retentio  alvi  is  very  often  dependent 
upon  weakness  or  paralysis  of  the  abdominal  muscles,  perhaps  from 
abdominal  pressure. 

Incontinentia  alvi  is  partly  the  result  of  inattention  on  the  part  of 
idiots,  the  insane,  those  who  are  unconscious;  on  the  other  hand,  it  is 
evidence  of  paralysis  which  either  only  manifests  itself  by  the  fact  that 
the  stool  cannot  be  retained  long  after  the  first  sense  of  desire,  or  that 
only  the  fluid  stool  cannot  be  held  back ;  lastly,  that  solid  as  well  as 
thin  stool  passes  each  time.  This  disturbance  may  occur  from  inter- 
ruption of  the  reflex  arc  centripetally  from  the  rectum  to  the  lumbar 
portion  of  the  spinal  cord,  and  thence  again  to  the  sphincter  muscles. 


EXA  MINA  TION  0  F  THE  NER  VO  US  SYSTEM.  579 

or  by  interruption  of  the  tracts,  centripetal  and  centrifugal,  between 
the  lumbar  cord  and  the  brain  (voluntary  defecation).  Involuntary 
discharge  of  the  stool  likewise  takes  place,  particularly  in  spinal 
diseases  both  of  the  lumbar  cord  and  of  the  portion  above  it.  In 
the  latter  case  the  discharge  seems  to  be  regulated  by  the  absence  of 
reflex,  but  without  the  influence  of  the  will ;  on  the  other  hand,  in 
destruction  of  the  lumbar  cord,  the  reflex  as  well  as  the  voluntary 
influence  is  annulled :  the  sphincter  is  relaxed,  the  scybala  escape  as 
they  are  carried  down  from  the  intestine.  The  same  thing  is  also 
observed  in  very  great  prostration. 

5.  Disturbances  of  the  Urinary  Apparatus. 

Oliguria,  anuria,  also  polyuria,  may  temporarily  affect  hysterical 
patients.  Polyuria  (diabetes  insipidus)  and  also  glucosuria  are  ob- 
served temporarily  or  continuously  with  local  diseases  of  the  oblongata, 
for  a  very  short  time  in  tabes,  and  when  there  is  considerable  increase 
of  the  intracranial  pressure.  On  the  other  hand,  in  genuine  diabetes 
mellitus  there  are  observed  a  number  of  nervous  disturbances :  neural- 
gia, neuritis,  deep  disturbances  of  the  nutrition  of  the  skin  and  the 
subcutaneous  cellular  tissue,  and  coma  which  appears  either  slowly  or 
suddenly  like  apoplexy. 

Cystitis,  from  the  slightest  to  the  most  severe  form,  is  observed 
when  there  is  difficulty  in  emptying  the  bladder  (which  see),  and  espe- 
cially (but  not  exclusively)  after  the  use  of  the  catheter.  It  is  par- 
ticularly an  important  and  frequent  complication  of  myelitis  transversa 
and  of  tabes. 

Further  particulars  regarding  the  condition  of  the  urine  are  given 
in  connection  with  the  urinary  apparatus  itself 

Involuntary  passage  of  the  urine  occurs  in  the  insane,  with  idiots, 
an  the  state  of  unconsciousness,  in  severe  diseases  of  any  sort ;  fur- 
ther, as  a  special  form  of  disease  in  enuresis  nocturna. 

Retentio  et  ineontinentia  urince,  however,  have  an  especial  role. 
With  the  former,  the  patient,  when  urinating,  must  press  or  wait  a 
little,  when  the  urine  gradually  comes  in  the  ordinary  way,  or  else  it 
escapes  very  slowly  in  a  small  stream,  or  the  bladder  cannot  empty 
itself  at  all  and  the  catheter  must  be  used.  Incontinence  often  first 
manifests  itself  as  under  reflex  control,  but  the  urine  is  passed  inde- 


580  SPECIAL  DIAGNOSIS. 

pendently  of  the  will,  or  simultaneously  with  retention  there  is  an 
after-trickling,  or  an  escape  of  the  urine  while  laughing,  coughing,  or 
in  severe  cases,  as  ischuria  paradoxa :  the  bladder  is  not  completely 
emptied,  sometimes  remains  always  abnormally  full,  but  from  time  to 
time  some  of  its  contents  escape ;  in  the  most  severe  cases  the  urine 
trickles  continually  from  the  constantly-full  bladder.  In  the  latter 
cases  there  is  complete  paralysis  of  the  bladder  (generally  of  the 
detrusor  as  well  as  of  the  sphincter). 

An  involuntary  passage  of  urine  which  is  under  reflex  control  re- 
quires an  intact  reflex  arc :  (a)  healthy  mucous  membrane  of  the 
bladder ;  (b)  sensitive  muscle ;  {c)  nerves ;  {d)  lumbar  spinal  cord ; 
(e)  muscles  of  the  bladder — hence  it  occurs  with  an  intact  lumbar 
cord,  but  one  which  is  cut  off"  from  the  brain :  myelitis  transversa 
dorsalis,  cervicalis,  or  traumatic  and  other  spinal  transverse  lesion. 
We  meet  with  complete  paralysis  of  the  bladder  chiefly  in  lesions  of 
the  lumbar  cord.  All  kinds  of  bladder  disturbance  occur,  from  the 
slightest  to  the  most  severe,  in  tabes.  Differential  diagnosis  comes 
chiefly  into  consideration  from  the  fact  that  disturbances  of  the  bladder 
are  absent  in  multiple  neuritis  (as  against  tabes) ;  further,  in  amyo- 
trophic lateral  sclerosis,  polio- myelitis  (as  against  myelitis). 

We  have  still  to  mention  the  [frequent,  but  not  invariable]  invol- 
untary passage  of  urine  in  attacks  of  genuine  epilepsy ;  it  is  wanting 
in  hystero-epilepsy,  and  so  it  is  important  for  differential  diagnosis. 

Bladder  crises  (painful  tenesmus)  are  observed  in  tabes. 

Lastly,  it  is  to  be  cited  that  the  most  varied  conditions  of  irritation 
of  the  penis  (especially  phimosis)  may  lead  to  enuresis,  pollution, 
other  nervous  disturbances  of  various  kinds. 

6.  Disturbances  of  the  G-enital  Apparatus. 

The  various  anomalies  of  the  male  genital  function  may  be  almost 
entirely  (with  the  exception  of  azoospermia  and  aspermatism)  func- 
tional and  organic,  and  in  the  latter  case  again  may  rest  upon  a  ner- 
vous as  well  as  some  other  form  of  disease.  From  the  standpoint  of 
diagnosis  of  nervous  diseases  the  decline  of  the  genital  function  is 
chiefly  of  importance  in  tabes,  as  against  chronic  multiple  neuritis. 
On  the  other  hand,  differential  diagnosis  from  neurasthenia  spinalis  is 
often  necessary,  and  it  is  to  be  remembered  that  in  the  latter  disease 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  581 

there  may  also  be  long-continued  marked  functional  disturbance  of  the 
activity  of  the  sexual  function. 

Of  the  female  genital  apparatus  very  little  needs  to  be  said  here. 
An  energetic  reaction  has  taken  place  against  the  etiological  relation, 
formerly  very  strongly  claimed,  between  anatomical  disturbances  and 
hysteria,  which  reaction,  in  turn,  is  going  too  far.  In  our  opinion, 
there  is  no  doubt  that  in  women  diseases  of  a  sexual  character  may 
cause  hysteria,  certainly  more  than  other  conditions  which  tend  to 
weaken  the  nervous  system  do. 

The  so-called  painful  ovary  or  ovarian  hypergesthesia,  sensitiveness 
of  the  hypogastric  region,  especially  on  the  left  side,  to  pressure  upon 
this  spot  (which  has  nothing  to  do  with  the  ovary)  is  not  unimportant 
in  hysteria  and  sometimes  causes  an  hysterical  spasm ;  also  [pressure] 
sometimes  arrests  an  existing  attack  [Charcot].  Similar  hystero- 
genous  zones  may  exist  in  other  regions  of  the  body  in  hysterical 
subjects. 

7.  Disturbances  of  the  Skin. 

A  number  of  diseases  of  the  skin,  apart  from  the  special  province 
of  dermatology,  rest  upon  a  neurotic  basis,  as  herpes,  sometimes  prob- 
ably also  pemphigus  ;  further,  the  so-called  glassy  skin ;  at  any  rate, 
each  of  these  may  be  regarded  as  a  disease  of  the  peripheral  nerves. 
Herpes  zoster,  especially  when  it  involves  the  intercostal  nerves,  has 
a  special  significance :  it  has  its  origin  in  compression  of  the  spinal 
cord,  in  tabes,  meningitis  spinalis  (here  probably  entirely  from  the 
roots  of  the  nerves),  in  disease  of  the  spinal  ganglion,  and  in  peripheral 
neuritis,  in  all  these  cases  generally  associated  with  neuralgic  pains. 
But  herpes  also  occurs  in  the  region  of  any  other  nerves,  as  the  tri- 
geminus. 

Regarding  herpes  labialis,  etc.,  see  under  acute  general  diseases, 
p.  50. 

In  all  diseases  of  the  nervous  system  we  must  search  carefully  for 
any  evidences  of  syphilis,  not  only  upon  the  skin  but  also  in  the  other 
organs  which  come  under  consideration. 

Regarding  local  perspiration  (see  p.  38)  we  sometimes,  although 
rarely,  have  local  anidrosis.  Among  the  laity  the  loss  of  perspiration 
of  the  feet  plays  an  important  part  as  the  supposed  cause  of  a 
number  of  diseases,  particularly  spinal,  as  tabes ;  it  is  probably  a  con- 
secutive, and  in  itself  an  indiflferent,  phenomenon  of  this  disease. 


582  SPECIAL  DIAGNOSIS. 

Hemorrhages  of  the  skin  occur  spontaneously  in  hysteria,  as  curi- 
osities ;  punctiform  ecchymoses  may  be  observed  upon  the  face,  chiefly 
in  the  neighborhood  of  the  eyes  after  epileptic  attacks.  Here,  also, 
we  more  frequently  have  hemorrhages  in  the  conjunctiva.  Hemor- 
rhages into  the  subcutaneous  tissues  take  place  after  injuries  received 
during  an  epileptic  attack.  The  significance  of  hemorrhages  into  the 
skin  and  subcutaneous  cellular  tissue  of  the  head  (especially  about  the 
eyes,  and  of  the  nose  in  fracture  of  the  base  of  the  skull),  is  treated 
of  in  the  works  upon  Surgery. 

Decubitus  is  an  ulceration  of  the  skin,  then  of  the  subcutaneous 
tissue  and  sometimes  of  the  deeper  tissues,  and  even  of  the  bone 
itself.  It  occurs  in  dependent  portions  of  the  body  upon  which  the 
patient's  weight  rests,  and  particularly  where  the  skin  covers  bony 
prominences,  as  the  sacrum,  the  heels,  the  scapulae.  Want  of  clean- 
liness, and  lying  upon  the  sacrum,  especially  when  there  is  inconti- 
nence of  stool  and  urine,  are  very  marked  exciting  causes. 

1.  Decubitus  acutus  (malignus).  It  at  first  manifests  itself  as  an 
erythema  exudativum,  then  vesicles  are  generally  formed,  whose  bases 
become  necrotic,  from  which  the  destruction  proceeds  rapidly  both  in 
area  and  depth.  Pressure  and  filth  are  marked  causes,  but  pressure 
alone  may  produce  the  ominous  exudative  erythema,  as  on  the  inner 
sides  of  the  knees  when  pressed  together  in  cases  of  adduction  con- 
tracture, where  we  once  saw  an  enormous  decubitus  acutus  form  in  a 
few  days.  Decubitus  acutus  has  been  seen  by  Charcot  in  hemiplegia 
upon  the  posterior  portion  of  the  paralyzed  side  two  to  four  days  after 
an  attack  of  apoplexy.  We  have  observed  it  only  in  severe  diseases 
of  the  spinal  cord. 

2.  Ordinary  decubitus  occurs  only  when  the  body  lies  so  that  pres- 
sure is  made  upon  one  place  and  with  the  concurrence  of  uncleanness ; 
it  may  be  entirely  prevented  by  proper  care.  It  also  begins  as  an 
erythema,  or  in  the  form  of  a  few  pustules,  or  a  cutaneous  hemor- 
rhage. It  occurs  in  all  organic  paralyses,  also  in  any  kind  of  cachexia, 
if  care  is  not  taken  to  prevent  it. 

Mai  perforant  [perforating  disease  of  the  foot]  is  a  destruction  of 
the  skin  and  deeper  parts  of  the  foot,  especially  of  the  heel  [sole  ?]. 
It  occurs  in  tabes,  in  progressive  paralysis,  also  in  diabetes.  Recently 
ulcerations  of  the  skin,  or  subcutaneous  tissues  in  syringo-myelitis  of 
the  cervical  cord  have  been  observed  (Schultze). 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  583 

Growth  of  hair  is  a  very  notable  anomaly  dependent  upon  a  neu- 
rosis. But  these  changes  have  no  independent  diagnostic  signifi- 
cance. 

The  nails  readily  become  claw-like,  angular  and  brittle  in  long-con- 
tinued severe  peripheral  paralysis. 

8.  Bpnes  and  Joints. 

We  observe  the  arrest  of  growth  of  bones  after  severe' central  paral- 
ysis during  the  period  of  childhood,  and,  likewise,  after  polio-myelitis 
acuta  it  is  generally  more  marked  than  after  encephalitis.  Abnormal 
brittleness  of  the  bones  is  frequently  seen  in  tabes.  In  severe  syringo- 
myelitis  of  the  cervical  cord,  there  are  severe  trophic  disturbances  of 
the  bones,  as  fractures,  periosteal  inflammations  with  separation  of 
sequestrum. 

Arthropathia  of  all  kinds  are  to  be  observed  in  diseases  of  the 
nervous  system  :  1.  Oi'ganic  arthropathia,  seldom  in  recent  hemi- 
plegia, occurring  more  frequently  as  stiffness  of  the  joints,  is  easily 
confounded  with  stiffness  and  sensibility  from  contracture.  It  occurs 
in  old  hemiplegias,  and  is  also  to  be  observed  as  serous  effusion  with 
periarticular  swelling  or  as  severe  deforming  arthritis,  also  causing 
new  formation  ;  both  the  latter  occur  in  tabes. 

2.  Joint  neuroses  occur  as  painful,  occasionally  exacerbating  affec- 
tions of  the  joint,  sometimes  with  points  of  pressure,  stiffness,  and 
contracture,  the  two  latter  disappearing  under  narcosis,  but  without 
any  sign  of  organic  disease. 

Under  the  name  of  acromegalia,  Marie  has  recently  described  a 
peculiar  disease,  which  consists  in  a  giant-like  enlargement  of  the 
feet,  hands,  nose,  inferior  maxilla,  and  certain  parts  of  the  skeleton, 
dependent  entirely  or  chiefly  upon  hypertrophy  of  the  bones. 

THE    DIAGNOSTIC    VALUE    OF    THE    SYMPTOMS    IN"    NERVOUS    DISEASES. 

In  diseases  of  the  nervous  system  the  individual  phenomena  combine 
to  form  complexes  of  symptoms  in  so  manifold  a  way  (much  more  than 
in  the  diseases  of  any  other  organ-system),  that  the  representation  of 
only  the  most  important  possible  combinations  would  very  much  ex- 
ceed the  limits  of  a  brief  work  upon  diagnosis.  Moreover,  for  the 
introductory  study  of  individual   diseases,  we  must   confess  that  we 


584  SPECIAL  DIAGNOSIS. 

think  the  method  of  special  pathology  which  compactly  presents  the 
picture  of  disease  on  the  lines  of  etiology,  anatomy  and  symptoms  is 
far  preferable  to  the  introduction  of  such  minutiae  into  a  text-book 
upon  diagnosis,  as,  if  this  and  that  phenomena  is  present,  then  the 
disease  is  so-and-so ;  but  if  we  have  this  and  that  other  phenomena, 
then  it  is  some  other  disease.  For  this  reason  we  add  here  only  a  few 
general  remarks. 

In  diseases  of  the  nervous  system  much  more  than  in  those  of  the 
rest  of  the  organism,  the  impression  stands  out  distinctly  that  we  in 
reality  have  to  estimate  the  phenomena  found  in  a  patient  in  twa 
ways.     We  must  ask  ourselves  : 

(a)  What  are  the  portions  of  the  nervous  system  whose  disease^ 
judged  by  their  nature  and  location,  has  caused  or  can  cause  the  pres- 
ent phenomena  ?  This  proceeds  upon  our  knowledge  of  the  anatomy, 
physiology  and  pathological  physiology  of  the  nervous  system,  which 
we  must  acquire  as  perfectly  as  possible. 

(5)  Does  the  picture  formed  by  all  the  symptoms  correspond  with 
any  disease  with  which  we  are  now  acquainted  ?  Then  comes  the 
further  question : 

(c)  What  light  does  the  etiology,  development,  and  course  of  the 
disease  throw  upon  its  nature,  and  sometimes  also  upon  its  location  ? 

The  lines  of  thought  designated  by  (a)  and  (5)  closely  interlock ; 
generally  both  are  employed  in  a  single  case.  In  certain  diseases, 
indeed,  we  are  wholly  or  almost  wholly  directed  to  the  latter,  (5),  which 
is,  so  to  speak,  unscientific,  particularly  in  certain  general  neuroses 
or  functional  diseases  (regarding  which,  see  below).  On  the  other 
hand,  we  are  fortunately  able,  in  local  diseases  of  the  brain,  of  the 
spinal  cord  and  of  the  peripheral  nerves,  to  proceed  upon  an  almost 
purely  anatomico-physiological  basis. 

In  order  to  make  a  diagnosis  of  the  location  of  a  local  disease, 
besides  the  special  knowledge  requisite  for  such  a  discrimination, 
one  must  have  a  certain  amount  of  practice  in  making  combinations, 
of  which  the  ability  to  keep  in  mind  the  topography  must  form  the 
basis.  (Let  it  be  here  once  more  repeated  that  our  preliminary 
anatomical  remarks  do  not,  by  any  means,  contain  all  that  has  been 
positively  determined  and  is  interesting  to  know,  but  are  rather  for 
the  purpose  of  instruction  in  topographical  thinking).  We  advise 
the  beginner,  who  wishes  to  train  himself  in  this  department,  to  begin 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  535 

"With  the  study,  for  instance,  of  peripheral  facial  paralysis,  the  different 
combinations  of  paralysis  of  cranial  nerves  at  the  base  of  the  brain, 
and  then  to  study  the  group  of  symptoms  in  the  cerebral  centres. 

In  order  to  arrive  at  a  conclusion  regarding  the  location  of  a  local 
disease  it  is  recommended,  as  the  result  of  experience,  that  we  should 
always  attempt  to  trace  the  diiferent  phenomena  back  to  a  focus ;  but 
it  is  evident  that  sometimes  there  will  be  several  foci.  Moreover,  the 
probability  that  there  is  only  one  focus  varies  with  the  supposed  nature 
of  the  disease ;  thus,  for  instance,  a  glioma  almost  always  occurs  as  a 
single  tumor,  while  metastatic  cerebral  abscesses  are  generally,  and 
thrombotic  foci  of  softening  very  often,  multiple. 

In  regard  to  local  diseases  of  the  brain  we  are  to  distinguish 
between  the  general  phenomena  as  respects  the  brain,  and  the  local 
symptoms.  The  general  brain  symptoms  are  essentially  those  relating 
to  increased  intracranial  pressure,  and  may  comprise  : 

(a)  Psychical  disturbances  (affecting  the  clearness  of  consciousness, 
of  inteUigence,  the  subjective  condition). 

{U)  Pain  in  the  head;  dizziness;  rigidity  of  the  pupils;  spasms; 
certain  phenomena  of  organic  life,  as  diminution  of  the  pulse,  vomit- 
ing, etc. 

Affections  that  develop  rapidly  and  are  of  limited  extent,  espe- 
cially hemorrhages,  also  other  disturbances  occuring  suddenly,  as 
emboli,  usually  produce  the  most  pronounced  general  phenomena. 
We  call  the  sudden  loss  of  consciousness,  sometimes  combined  with 
one  or  other  of  the  phenomena  mentioned  above,  an  apoplectic  attack. 

The  local  symptoms  are  divided  into  direct  and  indirect:  the 
former  are  dependent  upon  disturbances  of  the  centre  and  the  tracts 
which  are  regarded  as  irremediable,  the  latter  are  caused  by  all  sorts 
of  disturbances  (commotion,  "collateral  oedema,"  anaemia,  etc.)  in  the 
neighborhood  of  the  elements  that  are  really  injured — disturbances 
which  may  again  disappear,  and  which,  after  a  hemorrhage  or  emboli, 
always  disappear  in  the  course  of  months,  so  that  only  the  direct  local 
symptoms  caused  by  the  disturbance  itself  then  remain.  With  local 
growths  which  develop  slowly,  as  tumors,  these  indirect  local  symptoms 
may  often  change,  or  they  may  permanently  remain.  In  the  spinal 
cord,  when  there  are  local  diseases,  the  general  phenomena  do  not 
usually  play  such  an  important  role,  and  we  may  not  here  be  able 
sharply  to  separate  the  direct  and  indirect  local  symptoms. 


586  SPECIAL  DIAGNOSIS. 

But  in  all  diseases  of  the  nervous  system  all  possible  disturbances 
in  the  rest  of  the  organism  contain  diagnostic  points,  and  come  espe- 
cially under  consideration  in  local  diseases  of  the  brain  and  spinal 
cord  for  forming  a  judgment  as  to  the  nature  of  the  local  trouble.  We 
compare  what  was  said  upon  this  point  in  the  chapter  on  vegetative 
disturbances ;  but,  especially,  we  must  never  fail,  in  every  disease  of 
the  brain  and  spinal  cord,  to  take  into  consideration  the  possibility  of 
the  syphilitic  nature  of  the  disease  {when  there  is  the  slightest  sus- 
picion of  syphilis  the  treatment  is  to  conform  to  it). 

Under  the  anatomical  diseases  of  the  nervous  system,  in  every 
respect  the  so-called  systemic  diseases  have  a  special  place.  In  these 
conditions  the  disease  in  the  nervous  substance  is,  with  more  or  less 
regularity,  always  concerned  only  with  certain  elements,  which  sys- 
tematically (in  Fiechsig's  sense,  see  below)  belong  together,  while  other 
portions,  even  lying  very  close  to  the  diseased  ones,  remain  entirely 
healthy  :  the  disease  does  not  lay  hold  of  the  entire  region,  and  thus  it 
stands  in  sharp  distinction  from  the  inflammatory  diseases  and  all  new 
formations.  But  even  though  the  systemic  disease  lays  hold  upon  ele- 
ments of  the  same  function  (and  indeed  always  the  symmetrical  por- 
tions of  the  two  sides  ;  and  these  are  generally,  although  not  always, 
of  the  same  severity  upon  both  sides),  it  always  produces,  at  least 
in  its  main  features,  a  like  combination  of  symptoms.  If  several 
systems  are  affected  with  disease  at  the  same  time,  then  we  speak  of 
the  combined  system-disease.  Amyotrophic  lateral  sclerosis  furnishes 
the  most  clear  picture  of  a  combined  system-disease  which  may  affect 
the  whole  cortico -muscular  conducting  tract  from  the  cortex  to  the  mus- 
cles, but  always  leaves  all  the  rest  entirely  intact.  We  advise  every 
one  to  begin  the  study  of  the  system-diseases  with  this  remarkable 
one. 

Recently,  aside  from  the  systematic  nerve-trunk  degenerations,  we 
speak,  also,  of  systematic  nuclear  degeneration,  in  that  we  have 
somewhat  modified  the  idea  of  the  system  which  was  employed  by 
riechsig  only  for  the  bundles  of  fibres  which  showed  similarity  by 
the  point  of  time  when  their  medullary  sheath  was  formed  (and  which 
"  appeared  to  be  intercalated  between  apparatus  having  objects  of 
equal  value").  Hence,  and  not  incorrectly,  we  designate  the  disease 
itself  as  systematic  when  it  involves  "  apparatus  having  objects  of 
equal  value." 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  5^7 

In  conclusion,  we  make  a  few  further  remarks  regarding  the  differ- 
ential diagnosis  of  functional  and  anatomical  diseases  of  the  nervous 
system ;  this  differential  diagnosis  is  often  so  extremely  easy  that  the 
question  does  not  arise  at  all,  but  sometimes  it  is  extremely  difficult. 
The  points  of  departure  for  the  differential  diagnosis  are  arranged  in 
four  categories : 

1.  The  first  question  always  is  whether  the  general  picture  entirely 
corresponds  with  a  local  disease,  or  an  anatomical  or  functional  disease. 
It  is  to  be  remarked,  however,  that  hysteria  may  sometimes  exactly 
simulate  a  local  disease  of  the  brain. 

2.  There  are  certain  symptoms  of  palpable  disease  that  are  entirely 
unmistakable.  These  are :  the  reaction  of  degeneration  (or  rapidly 
developed  and  very  decided  atrophy  and  laxness  of  the  paralyzed 
muscles  (compare,  further,  what  was  said  on  p.  493  regarding  atrophy 
in  hysterical  paralysis) ;  choked  disc  and  reflex  rigidity  of  pupils  are 
also  symptoms.  Not  absolutely  certain,  although  pointing  quite 
decidedly  to  a  palpable  disease,  are  :  absence  of  tendon  reflex  ;  in 
unilateral  affections,  the  unilateral  absence  of  abdominal  reflex,  and 
very  marked  disturbance  of  the  bladder. 

3.  There  is  one  almost  certain  sign  of  functional  disease :  a  sudden 
return  to  a  perfectly  normal  condition  after  long  persistence  of  a  dis- 
eased condition,  or  the  sudden  occurrence  of  new  and  different  phe- 
nomena with  the  disappearance  of  those  previously  existing.  There 
are  other  signs  of  functional  (hysterical)  diseases  which,  in  combina- 
tion, cannot  mislead ;  these  are  the  stigmates  liysteriques  (Charcot)  : 
hysterical  hemiansesthesia,  concentric  limitation  of  the  field  of  vision, 
characteristic  spasms,  sometimes  hysterogenic  zones. 

4.  As  regards  cerebral  symptoms,  marked  development,  or,  on  the 
other  hand,  the  absence,  of  a  disturbance  of  the  sensorium  and  the  in- 
telligence, decides  the  question.  Also,  continuous  fever  and  rapid 
decline  of  strength  indicates  an  anatomical  disease. 


APPENDIX. 


We  present  here  a  very  brief  sketch  regarding  the  examination  of 
the  larynx  with  the  mirror  and  the  revelations  of  the  ophthalmoscope, 
so  far  as  they  are  related  to  internal  diseases,  especially  to  the  diseases 
of  the  nervous  system.  Lastly,  there  follows  a  review  of  the  life  his- 
tory of  those  pathogenic  bacteria  which  have  any  part  in  the  diag- 
nosis of  internal  diseases. 

We  pass  over  entirely  the  examination,  with  the  mirror,  of  the  nose 
and  ears,  because  these  pertain  chiefly  to  the  diseases  of  these  organs 
themselves,  and  are  very  rarely  of  significance  for  recognizing  any 
other  diseases.  Besides,  with  reference  to  the  latter  view,  we  have 
already  (pp.  573  and  575)  referred  to  the  diseases  of  the  nose  and  ears 
which  do  sometimes  come  under  consideration. 

1.  Laryngoscopic  Examination  of  the  Larynx} 

Instruments  and  sources  of  light.  Tiirck's  reflector  with  a  head- 
band is  most  frequently  recommended  for  illuminating  the  throat.  As 
the  laryngeal  mirror  we  employ  a  round  mirror,  with  a  diameter  of  20 
to  25  mm.,  fixed  to  a  stafi"  at  an  angle  of  120  to  125  degrees.  The 
staff"  is  fixed  to  a  handle  or  it  is  screwed  into  a  handle  prepared  for  it. 

For  a  source  of  light  we  may  employ  any  sufficiently  powerful  oil- 
or  gas-lamp.  The  lamp  is  placed  close  to  the  head  of  the  person  to 
be  examined,  so  that  the  light  from  the  reflector  is  thrown  at  the 
smallest  possible  angle  into  the  throat  of  the  person  being  examined. 
If  it  can  be  had,  sunlight  is  better  than  artificial  light.  It  is  employed 
either  in  such  a  way  that  the  patient  sits,  with  his  eyes  closed,  facing 
the  sun,  and  the  light  is  allowed  to  fall  directly  into  the  throat  or  so 
that  the  sunlight  is  thrown  by  the  reflector  into  the  throat.     If  the 

1  Let  it  be  distinctly  understood  that  the  above  only  contains  the  most  essential 
points  which  are  of  use  in  the  examination  itself.  They  cannot  and  should  not  take 
the  place  of  the  study  of  these  subjects  in  a  medical  course. 

(589) 


590 


APPENDIX. 


sunlight  is  glaring,  we  employ  a  special  mirror  with  a  longer  focus  (or 
a  plane  mirror),  because  the  ordinary  reflector  would  make  a  too  glar- 
ing light,  and  sometimes  even  produce  an  uncomfortable  sense  of  heat 
in  the  throat.  Electric,  magnesium,  and  other  lights  are  at  present 
too  expensive  to  take  the  place  of  sunlight. 

In  making  the  examination  we  sit  directly  in  front  of  the  patient, 
have  him  open  his  mouth,  set  the  reflector  at  the  proper  angle,  then 
warm  the  laryngeal  mirror  a  little  over  a  spirit-lamp  (testing  its  tem- 
perature by  placing  it  against  the  back  of  the  hand),  have  the  patient 
put  out  the  tongue,  seize  it  with  a  napkin  or  handkerchief  and  draw 
it  out  [as  far  as  possible.  It  is  well  to  have  the  head  thrown  quite 
well  back.].  Holding  the  mirror  as  one  would  a  pen,  it  is  to  be  slowly 
and  carefully  introduced  into  the  mouth,  and  then  the  patient  required 
to  distinctly  pronounce  "  ge,"  at  the  same  time  giving  the  proper  direc- 
tion to  the  mirror  as  it  is  pushed  as  far  back  as  possible  into  the  phar- 
yngeal cavity,  slightly  pressing  up  the  soft  palate.  The  parts  are  now 
brought  into  view  by  elevating  the  mirror,  depressing  it,  turning  it 

Fig.  169. 


Laryngoscopic  view  of  the  larynx  during  quiet  breathing  (after  Heitzmann),  double  size. 


now  to  the  right,  then  to  the  left,  and  revolving  it,  both  during  quiet 
respiration  and  phonation. 

The  mirror  must  be  most  scrupulously  cleaned  with  every  examina- 
tion. It  is  not  necessary  to  employ  a  special  mirror  with  patients 
who  are  manifestly  syphilitic. 

Irritability  of  the  pharynx  (strangling,  vomiting)  may,  with  prac- 


APPENDIX.  591 

tice,  be  avoided.  In  very  obstinate  cases  we  can  employ  cocaine. 
(See  the  special  text-books  regarding  other  obstacles  and  the  ways  of 
meeting  them.) 

In  the  laryngoscopic  image  the  parts  that  are  anterior  appear  as  the 
posterior ;  on  the  other  hand,  what  is  upon  the  right  hand  of  the  pa- 
tient remains  upon  the  right ;  the  examiner  has,  of  course,  the  right 
vocal  cord  of  the  patient  upon  his  left  side. 

We  observe  (see  Fig.  169)  :  1.  The  base  of  the  tongue,  the  glosso- 
epiglottic  ligaments,  the  epiglottis,  lig.  aryepiglottica  with  the  carti- 
lages of  Wrisberg.  2.  The  arytenoid  cartilage,  or  the  cartilage  San- 
torini,  the  false  vocal  cords,  the  sinus  Morgagni.  3.  The  ligamenta 
glottidis  vera,  with  the  vocal  process  of  the  arytenoid  cartilage.  4. 
The  region  between  the  arytenoid  cartilages,  pars  interarytsenoidea 
(the  posterior  wall  of  the  larynx) ;  the  subcordal  region,  or  the  fore- 
shortened trachea.     The  illumination  must  be  strong. 

It  is  advisable  for  those  who  have  had  but  little  experience  to  first 
fix  the  landmarks  by  the  shining  white  prominent  true  vocal  cords, 
and  from  thence  to  examine  the  individual  parts  of  the  laryngeal 
picture  one  after  the  other. 

The  examination  with  the  laryngeal  mirror  is  directed  to  three 
things :  the  form  and  the  color  of  the  parts  of  the  larynx,  and  the 
position,  or  motion  of  those  that  move. 

As  to  the  form  of  the  several  portions  of  the  inside  of  the  larynx  it 
is  to  be  remembered  that  the  representation  given  in  Fig.  169  is,  of 
course,  only  schematic.  Repeated  examinations  of  normal  larynges 
will  show  the  variations  and  fix  them  in  mind.  The  form  of  the  epi- 
glottis varies  very  much ;  this  is  also  true  of  the  arytenoid  cartilage 
and  the  false  vocal  cords  or  the  opening  of  the  ventricle  of  the  larynx. 

The  color  of  the  mucous  membrane  of  the  larynx,  with  the  excep- 
tion of  the  true  vocal  cords,  is  tolerably  uniform  and  corresponds  some- 
what with  that  of  the  hard  palate.  Very  often  the  upper  border  of 
the  epiglottis,  and  sometimes  its  upper  surface,  is  lighter,  even  yellow- 
ish-red. Above  the  arytenoid  cartilages,  the  color  of  the  mucous 
membrane  varies  considerably :  sometimes  it  is  exactly  like  the  other 
parts,  sometimes  darker,  again  lighter,  and  then  yellowish.  The  true 
vocal  cords  are  shining  white ;  in  individual  cases,  with  the  function 
perfectly  normal,  they  are  slightly  rosy.  At  the  vocal  process  there 
is  a  circumscribed  yellowish  spot. 


592  '  APPENDIX. 

f 

We  must  be  on  guard  against  being  misled  by  deposits  of  mucus 
or  of  pus  from  the  lungs.  These  deposits  may  be  superficial,  or  may 
conceal  deep  ulcerations,  loss  of  substance,  croupous  deposits.  If 
in  doubt,  require  the  patient  to  cough.  If  still  uncertain,  have  the 
patient  inhale  the  vapor  of  steam  for  a  few  minutes,  and  then  repeat 
the  examination. 

I»[ormally  the  positions  and  movements  of  the  portions  of  the  larynx 
are  perfectly  symmetrical,  although  it  is  to  be  remarked  that  if  the 
mirror  is  not  properly  held  in  position,  the  parts  may  easily  appear  to 
be  unsymmetricai.  During  quiet  respiration,  the  rima  glottidis  is  tol- 
erably widely  opened — at  least  so  that  the  whole  breadth  of  the  true 
vocal  cords  is  visible ;  the  arytenoid  cartilage  (cartilage  of  Santorini) 
can  be  seen  between  the  pars  interarytsenoidea  (posterior  wall  of  the 
larynx) ;  with  active  deep  inspiration,  the  vocal  cords  separate  from 
each  other  still  more,  so  that  they  almost  or  quite  disappear  under  the 
false  vocal  cords  (which  likewise  stand  apart.  During  phonation,  the 
vocal  cords  come  so  closely  together  that  either  no  slit  between  them, 
or  scarcely  any,  can  be  seen.  Generally  their  median  edges  form  a 
perfectly  straight  line.  But  in  individual  cases,  only  the  pares  liga- 
mentosse  close  so  sharply,  and  posterior  to  the  process,  vocales  (that 
is,  the  pars  cartilaginea),  the  vocal  cords  remain  somewhat  more  apart, 
leaving  a  triangular  space  between  them. 

When  the  glottis  is  closed  the  arytenoid  cartilages  come  near  to- 
gether and  the  pars  interarytsenoidea  disappears ;  on  the  other  hand, 
the  false  vocal  cords  leave  a  tolerably  broad  space  between  each  other, 
through  which  we  see  the  true  vocal  cords. 

Patliological  conditions.  Since  we  here  come  upon  a  subject  that 
has  already  been  frequently  referred  to,  in  what  follows  we  bring 
forward  only  those  conditions  which  have  relations  to  other  internal 
diseases,  and  treat  of  them  in  the  briefest  way. 

We  do  not  meet  with  paleness  of  the  mucous  membrane  of  the 
larynx  as  a  local  condition.  Also,  it  is  no  longer  of  importance  in 
the  recognition  of  a  general  anaemia,  because  this  is  much  easier  deter- 
mined by  the  paleness  of  the  skin,  lips,  etc.  Only  one  circumstance 
needs  mention,  that  tuberculous  infiltration  and  ulceration,  in  contrast 
with  other  kinds,  as  syphilitic,  often  accompanies  a  very  striking  gen- 
eral paleness  of  the  mucous  membrane  of  the  larynx.  Abnormal  red- 
ness of  the  mucous  membrane  of  the  larynx,  without  other  changes, 


APPENDIX.  593 

occurs  in  febrile  liypersemia  of  all  the  mucous  membranes  and  in  gen- 
eral or  local  engorgement  (the  latter  caused  by  pressure  upon  the 
larynx  by  tumors,  from  engorgement  in  the  region  of  the  cava  supe- 
rior). Also,  whenever  there  is  any  redness  of  the  larynx  it  must,  as 
a  matter  of  course,  lead  us  to  examine  most  carefully  for  any  possible 
other  changes  (ulcerations,  swellings,  etc.). 

Redness,  swelling,  and  sometimes  secretion,  are  the  signs  of  catofrrli. 
Acute,  as  well  as  chronic  laryngeal  catarrh  may  involve  various  loca- 
tions :  for  example,  it  may  attack  the  upper  portion  of  the  larynx, 
leaving  the  glottis  free  ;  it  may  also  attack  only  the  glottis.  A  simple 
catarrh  is  always  symmetrical.  Acute,  as  well  as  chronic  catarrh  may 
cause  motor  disturbances :  on  the  one  side  this  may  be  due  either  to 
the  swelling  of  the  mucous  membrane  (especially  of  the  incisura  inter- 
arytsenoidea,  preventing  the  closure  of  the  glottis),  or,  to  paralysis  of 
the  tensor  of  the  vocal  cords  or  the  adductors. 

Acute  laryngitis,  especially  in  children,  may  give  rise  to  apparent 
stenosis  by  reason  of  the  swelling. 

It  is  to  be  especially  remembered  that  chronic  and  recurrent  acute 
catarrh,  and  likewise,  no  doubt,  simple  catarrh,  are  very  frequent  in  all 
chronic  diseases  of  the  lungs  and  especially  in  tuberculosis.  It  is, 
further,  important  to  remember  that  behind  a  chronic  catarrh  a  tuber- 
culous or  syphilitic  (or  lupous)  new  formation  may  for  some  time  be 
concealed.  A  swelling  which  is  limited  to  or  elects  the  interarytsenoid 
region  is  always  very  highly  suspicious  of  tuberculosis. 

Laryngitis  hypoglottica  (von  Ziemssen)  is  an  especially  severe  form 
of  acute,  as  well  as  chronic,  catarrh.     In  this 
disease  we  see  beneath  the  vocal  cords  some-  ^'^'       ' 

times  merely  a  soft  rosy  border,  which  can  only 
be  seen  during  inspiration ;  sometimes  a  firm, 
grayish-red,  smooth  or  uneven  lump  (see  Fig. 
170).  It  is  almost  always  present  upon  both 
sides.  These  subcordal  swellings  appear  to  Swelling  below  the  vocal 
vary  a  good  deal  as  to  their  nature  :  sometimes    '"^'"'^^  ^''"'^  laryngitis  hy- 

■,.-,-,  T  .1  poglottica  chronica  (after 

they  are  simply  due  to  oedema ;  m  other  cases,     ziemssen). 
to  a  simple  catarrh ;  in  still  others,  to  submu- 
cous infiltration.     Further,  such  a  subcordal  laryngitis  may  be  or  may 
become  tuberculous  in  its  nature ;  more  rarely  it  is  syphilitic.     From 
the  condition  of  the  larynx  alone  it  is  extremely  difficult  to  make  the 

38 


594 


APPENDIX. 


diiFerential  diagnosis  of  these  specific  diseases  from  simple  catarrh,  as 
well  as  between  syphilis  and  tuberculosis.  There  may,  however,  be 
other  alterations  of  the  larynx  present,  or  unquestionable  signs  in  other 
organs,  which  throw  light  upon  the  matter.  The  serious  character  of 
laryngitis  hypoglottica  is  manifested  by  the  fact  that  very  frequently, 
and  sometimes  very  suddenly,  it  causes  severe  stenosis. 

Marked  swelling  of  the  whole  larynx  or  of  certain  portions  of  it 
indicates  oedema  or  phlegmon — that  is,  severe  submucous  inflammation 
which  ends  in  abscess.  Both  of  these  will  chiefly  be  distinguished  by 
the  color  of  the  mucous  membrane,  which  is  pale  when  there  is  non- 
inflammatory oedema,  even  yellowish  and  often  shaking  like  jelly, 
while  in  phlegmonous  inflammation  it  is  deep  red.  Midway  between 
these  two  conditions  stands  inflammatory  oedema,  which  pathologico- 
anatomically  and  genetically  cannot  be  sharply  distinguished  from 
phlegmonous  infiltration.  Severe  phlegmon  may  lead  to  decided  dis- 
figurement of  the  larynx  (see  Fig.  171).  This  may  also  be  true  of 
oedema,  as  is  shown  in  Fig.  172.  Circumscribed  laryngitis  phlcg- 
monosa  usually  results  in  the  formation  of  abscess,  or  it  may  occasion 
a  submucous  or  perichondrial  formation  of  pus. 


Fig.  171. 


Fig.  172. 


Phlegmonous  laryngitis,  with  phthisi- 
cal ulcer,  a,  epiglottis;  h,  left  aryepi- 
glottic  fold ;  c, left  pyriform  sinus.  (From 
ZiEMsSEN  after  Turck.) 


Extensive  phthisical  ulceration  of  the 
larynx,  marked  stenosis  of  the  larynx 
from  oedema.  a,  right  aryepiglottic 
fold ;  h,  anterior  portion  of  the  right 
cord.     (From  Ziemssen  after  Tueck.) 


Both  these  conditions  are  extremely  dangerous,  because  they  very 
easily  result  in  stenosis,  and  sometimes,  if  they  are  acute,  with  re- 
markable suddenness.  Phlegmonous  laryngitis  sometimes  results  in 
the  formation  of  pus  in  the  larynx  (especially  perichondritis),  or  its 
neighborhood  (as  angina  Ludovici).  Laryngeal  catarrh  very  seldom 
terminates  as  a  phlegmon ;  foreign  bodies,  and  substances  that  irritate 
chemically  and  as  escharotics,  may  produce  it ;  and  lastly,  it  occurs  in 


APPENDIX.  595 

various  acute  infectious  diseases,  either  resulting  in  catarrhal  or  ulcer- 
ative processes,  or,  it  would  seem,  as  independent  metastatic  diseases. 
Inflammatory  oedema  may  be  the  result  in  all  of  these  cases,  besides 
or  instead  of  phlegmon.  Simple  oedema  is  rare  and  chiefly  occurs 
with  general  dropsy  of  all  kinds,  and  in  local  obstruction  (as  in  struma, 
mediastinal  tumors). 

Ulceration  seldom  occurs  in  the  larynx  with  simple  catarrh,  more  * 
frequently  in  acute  infectious  diseases,  especially  in  typhus  abdominalis 
[typhoid  fever]  and  variola,  but  most  frequently  in  syphilis  and  tuber- 
culosis.   We  limit  ourselves  to  a  description  of  the  two  last-named  forms. 

Syphilitic  ulceration  in  the  larynx  occurs  almost  exclusively  in 
connection  with  pharyngeal  syphilis.  It,  by  preference,  attacks  the 
upper  section  of  the  larynx,  but  it  may  appear  in  the  glottis.  In  the 
majority  of  cases  a  single  ulcer  is  observed.  The  ulcers  have  reddened 
edges,  with  a  more  or  less  shallow,  whitish  deposit  upon  a  vocal  cord,  or 
the  epiglottis,  or  there  is  a  very  deep  crater-like  cavity  with  a  whitish 
deposit  and  sharp  or  swollen  border.  By  the  absence  of  knotty  ele- 
vations of  the  border  they  are  sharply  distinguished  from  carcino- 
matous ulcers.  On  the  other  hand,  it  is  often  difiicult  to  distinguish 
them  from  tubercular  ulcerations.  Here  the  differentiation  is  made 
by  other  signs  of  syphilis  or  tuberculosis  that  may  be  present. 

Regarding  gummata  of  the  larynx,  see  below.  Syphilitic  infiltra- 
tion without  ulceration  and  without  other  associated  signs  of  syphilis 
are  very  difficult  to  diagnose.  These  slighter  syphilitic  changes, 
moreover,  very  seldom  come  under  examination,  because  they  do  not 
usually  cause  any  inconvenience.     See  special  Avorks  regarding  them. 

Tubercular  ulceration  develops  from  tubercular  infiltration  The 
principal  location  to  be  mentioned  is  the  region  of  the  interarytsenoid 
space.  The  regions  next  most  frequently  attacked  are  the  arytaenoid 
cartilages  and  the  false  vocal  cords.  Tuberculous  ulcers,  with  the  excep- 
tion of  those  upon  the  glottis,  are  more  frequently  multiple  than  are 
syphilitic.  They  are  either  very  superficial  and  yellowish  in  color,  or 
deep  with  swollen  edges,  sometimes,  especially  in  the  interarytsenoid 
space,  with  papillomatous  mucous  proliferations.  Although  not  path- 
ognomonic (Grottstein),  the  latter  form  is  in  the  highest  degree  char- 
acteristic of  tuberculosis.  Further,  a  pale  oedematous  condition  of  the 
rest  of  the  mucous  membrane  points  to  tuberculosis.  The  most  im- 
portant factor  is  the  discovery  of  tubercle  bacilli  in  the  sputum.    These 


596 


APPENDIX. 


may  come  from  the  larynx  or  from  the  lungs,  which  latter  are  always, 
or  almost  always,  the  first  to  be  attacked. 

Deep  ulcerations  may  lead  to  perichondritis  laryngea.  The  most 
frequent  form  is  perichondritis  arytsenoidea.  Perichondritis  causes  a 
very  marked  swelling  and  redness,  generally  over  quite  a  large  area. 
It  very  easily  passes  from  this  condition  of  swelling  or  collateral  oedema 
into  stenosis.  If  it  ruptures  into  the  larynx,  then  the  necrotic  pieces 
of  cartilage  will  be  coughed  out,  and  sometimes,  when  examining  with 
the  laryngeal  mirror,  we  see  them  lying  loose. 

Scars  are  found  in  the  larynx,  as  elsewhere,  after  healing  from  loss 
of  substance.  Those  that  chiefly  interest  us  are  the  syphilitic.  These, 
more  than  others,  are  inclined  to  retract,  and  hence  they  not  infre- 
quently result  in  stenosis.  We  either  find  a  partial  adhesion  of  the 
vocal  cords  or  extensive  cicatricial  adhesions  of  the  true  and  false  vocal 
cords,  with  a  funnel-shaped  narrowing  downward,  etc.  It  is  generally 
impossible  to  form  any  conclusion  as  to  the  nature  of  the  antecedent 
processes  from  the  scar.  Only  this,  further,  is  to  be  said,  that  most 
laryngologists  now  agree  that  tubercular  ulcers  may  cicatrize. 

Excepting  the  syphilitic  gummata,  new  formations  in  the  larynx 
have  only  a  local  significance.  Gummata  are  either  solitary  nodules 
or  a  group  of  individually  small  nodules,  at  first  red  in  color,  with  a 
crinkled  contour.  They  are  inclined  to  .break  up  rapidly,  and  then 
to  be  replaced  by  deep  ulcers. 


Fig.  173. 


Fig.  174. 


Pedunculated  fibroma  upon  the  under 
surface  of  the  left  vocal  cord;  position 
during  inspiration  (Ziemssen). 


Epithelial  carcinoma  of  the  right  vocal 
cord  (Ziemssen). 


The  other  new  formations  may  be  divided  into  benign  and  malig- 
nant. Of  the  former,  very  much  the  most  frequent  are  the  papilloma ; 
more  rare  are  the  fibroma.  Both,  but  especially  the  latter,  are  gen- 
erally located  upon  the  vocal  cords.     Papilloma  are  sometimes  fiat, 


APPENDIX.  597 

wart-like,  sometimes  regular  papules,  often  multiple,  cauliflower-like. 
The  fibroma  are  genei'ally  pedunculated;  the  surface  is  usually- 
smooth,  while  that  of  the  papilloma  is  uneven  or  villous.  All  the 
other  benign  new  formations  (lipoma,  cysts,  etc.)  are  extremely  rare. 

The  malignant  new  formations  are,  in  the  great  majority  of  cases, 
carcinoma.  They,  like  the  papilloma,  generally  develop  from  the 
vocal  cords ;  next  in  frequency,  from  the  false  vocal  cords.  They 
manifest  great  inclination  to  necrosis  and  ulceration.  The  difieren- 
tial  diagnosis  of  carcinoma,  so  long  as  there  is  no  ulceration,  is  to  be 
made  from  papilloma,  after  the  occurrence  of  ulceration  from  tubercu- 
losis and  syphilitic  ulceration  :  generally  this  is  not  easy.  For  par- 
ticulars, we  must  refer  to  special  works.  Sarcoma  of  the  larynx  is 
much  more  rare  than  carcinoma. 

In  reference  to  the  more  unusual  diseases  of  the  larynx,  like  lupus 
and  lepra,  we  refer  to  special  works. 

Spasms  of  the  muscles  of  the  larynx  are,  for  the  most  part,  not  at 
all,  or  only  exceptionally,  observed  with  the  laryngoscope.  We  here 
only  mention  phonic  and  inspiratory  functional  spasm  of  the  glottis 
in  adults.  The  former  takes  place  at  the  instant  when  the  efibrt  at 
phonation  is  made,  when  a  decided  closure  of  the  glottis  takes  place, 
as  can  be  recognized  with  the  laryngoscope ;  on  the  contrary,  in  the 
latter  the  vocal  cords  close  at  the  instant  of  inspiration,  hence,  at  the 
time  when  they  ought  to  separate.  During  expiration  the  glottis  is 
normal,  or  almost  normally  open,  in  opposition  to  paralysis  of  the 
[crico-aryteenoidci]  postici  muscles  (see  below),  in  which  they  are  very 
close  together  during  expiration  also. 

As  disturbances  of  coordination,  both  of  these  conditions  will  be 
understood  from  their  analogy  to  the  neuroses  caused  by  certain  occu- 
pations affecting  the  upper  extremity  (writers'  cramp,  etc.),  and  are 
to  be  accounted  for  by  over-strain. 

Paralysis  of  the  Muscles  of  the  Larynx. 

Paralysis  of  all  the  muscles  that  close  the  larynx  (the  crico-arytse- 
noideus  lateralis,  arytaenoideus  transversus,  thyreo  arytsenoideus  ext. 
et  internus — all  supplied  by  the  recurrent  nerve) :  during  phonation 
the  vocal  cords  do  not  come  close  together,  but  remain  in  the  position 
of  inspiration.     Complete  aphonia  is  thus  produced.     The  paralysis 


598 


APPENDIX. 


is  generally  bilateral,  and  is  almost  always  due  to  hysteria  as  a  basis. 
Hence,  it  is  often  combined  with  anaesthesia  of  the  larynx. 

Paralysis  of  the  arytsenoideus  transversus :  during  phonation  the 
most  posterior  portion  of  the  glottis  (the  pars  cartilaginea)  does  not 
close.  As  a  result  we  have  hoarseness,  even  to  complete  aphonia.  It 
not  infrequently  occurs  with  acute  laryngitis.     (See  Fig.  175.) 

Paralysis  of  the  thyreo-arytsenoideus  intern.,  one  or  both  sides, 
causes  imperfect  closure  of  the  glottis ;  when  both  sides  are  paralyzed 
there  is  a  very  narrow,  symmetrical  oval  fissure  (see  Fig.  176) ;  with 


Fig.  175. 


Fig.  176. 


Paialysis  of  the  arytsenoideus  lu  acute 
laryngitis  (after  Zibmssen).  The  poste- 
rior portion  of  the  glottis  remains  open 
during  phonation. 


Paralysis  of  both  thyreo-arytaenoidei 
interni,  resulting  from  acute  laryngitis 
(Ziemssen).     Position  during  phonation. 


unilateral  paralysis,  a  correspondingly  narrow,  unsymmetrical  fissure. 
It  occurs  in  laryngitis,  but,  also,  often  in  hysteria. 

Paralysis  of  the  crico-arytsenoidei  postici  muscles,  the  openers  of 
the  glottis  (recurrent  nerve) ;  posticus  paralysis :  the  vocal  cords  in 
bilateral  paralysis,  during  expiration,  stand  near  together,  and  during 
inspiration  still  closer,  sometimes  in  apposition ;  phonation  may  be 
quite  normal.  Hence,  there  is  inspiratory  dyspnoea,  with  inspiratory 
stridor.  The  dyspnoea  may  increase  until  there  is  asphyxia.  In 
unilateral  posticus  paralysis  the  paralyzed  vocal  cord  is  motionless 
and  lies  near  the  middle  line,  while  upon  the  sound  side  there  are 
normal  motions. 

In  its  etiology,  posticus  paralysis  is  in  many  cases  obscure.  Some- 
times it  forms  the  beginning  of  a  bilateral  recurrent  paralysis ;  in 
other  cases  it  seems  to  have  a  muscular  origin  (gumma  in  the  muscle, 
laryngitis  with  atrophy,  etc.). 

Recurrent  paralysis — that  is,  paralysis  of  all  the  muscles  supplied 
by  the  recurrent  nerve — causes  the  vocal  cords  to  assume  the  so-called 


APPENDIX. 


599 


cadaver  position — the  position  with  reference  to  each  other  that  they 
have  during  quiet  breathing.  In  severe  paralysis,  the  vocal  cords  are 
entirely  stationary  in  this  position.  In  incomplete  paralysis,  they 
still  make  slight  motions  outward  and  also  show  an  inclination  to 
assume  the  position  of  adduction,  for  which  there  is,  as  yet,  no  undis- 
puted explanation.  When  the  paralysis  has  continued  for  a  long 
time  the  vocal  cords  become  atrophied. 

Bilateral  recurrent  paralysis  produces  bilateral  cadaver-position  of 
the  vocal  cords,  and  thus  complete  aphonia,  with  inability  to  cough. 


Fig.  177. 


Fig.  178. 


Bilateral  complete  posticus  paralysis 
(paralysis  of  the  crico-aiytsenoidei  pos- 
tici,  dilatation  of  glottis)  at  the  moment 
of  inspiration  (-Ziemssen). 


Position  during  inspiration  in  paral- 
ysis of  the  left  vocal  cord,  or  recurrent 
conduction  paralysis  (after  Ziemssen). 
Position  and  immobility  of  the  left  vocal 
cord,  as  in  the  cadaver. 


This  is  caused  by  compression  of  both  recurrent  nerves  from  aneu- 
rism of  the  aorta,  carcinoma  of  the  oesophagus,  and  enlarged  glands. 
It  will  be  readily  understood  that  this  bilateral  paralysis  from  periph- 
eral causes  is  much  more  rare  than  unilateral.  Complete  or  incom- 
plete bilateral  paralysis  of  the  recurrent  nerve  has  been  observed  with 
bulbar  paralysis,  tumors,  softening  of  the  medulla,  and  compression 
of  the  vagi  after  their  exit  from  the  medulla. 

Unilateral  recurrent  paralysis  is  much  more  frequent.  It  may  be 
easily  overlooked,  because  the  voice  is  often  clear,  although  weak,  for 
the  reason  that  the  sound  vocal  cord  during  phonation  reaches  beyond 
the  middle  line.  The  paralyzed  vocal  cord  during  quiet  breathing 
stands  in  the  cadaver-position,  the  sound  one  in  the  position  of  rest — 
that  is,  somewhat  more  widely  abducted  than  the  other.  During 
phonation  the  necessary  closure  of  the  glottis  takes  place,  because  the 
healthy  vocal  cord  overreaches;  but  then  the  glottis  is  necessarily 
askew.  Unilateral  paralysis  of  the  recurrent  nerve  is  almost  always  due 
to  compression  of  the  nerve  in  the  neck  or  as  it  passes  into  the  thorax ; 


600  APPENDIX. 

this  will  be  brought  about  by  the  same  causes  as  bilateral  peripheral 
recurrent  paralysis.  Thus,  recurrent  paralysis  may  be  an  important 
corroborative  symptom  of  aneurism,  of  carcinoma  of  the  oesophagus, 
or  of  any  other  kind  of  mediastinal  tumor.  When  there  is  a  suspicion 
of  one  of  these  conditions,  we  may  almost  regard  a  recurrent  paralysis 
as  decisive ;  at  any  rate,  the  existence  of  a  recurrent  paralysis  has 
often  given  the  first  suggestion  that  led  to  a  discovery  of  an  aneurism 
or  of  carcinoma  of  the  oesophagus. 

Paralysis  of  the  tensor  of  the  vocal  cords  (crico-thyreoidei  muscles, 
superior  laryngeal  nerve)  is  very  seldom  observed,  and  then  it  is 
always  combined  with  anaasthesia  of  the  mucous  membrane  and  paral- 
ysis of  the  epiglottis.  It  is  a  tolerably  dangerous  condition,  because 
of  the  accompanying  difficulty  of  swallowing  and  the  risk  of  degluti- 
tion-pneumonia. The  glottis  is  not  exactly  steady,  but  oscillating. 
In  unilateral  paralysis  the  normal  vocal  cord  stands  higher. 

Paralysis  of  the  tensor  of  the  vocal  cords  takes  place  most  frequently 
in  diphtheria,  but  then  it  is  always  accompanied  with  paralysis  of 
other  muscles. 

2.  Examination  with  the  Ophthalmoscope.  . 

This  method  of  examination  strictly  belongs  in  the  province  of 
ophthalmology.  Therefore  we  limit  ourselves  simply  to  its  use  for  the 
purpose  of  diagnosis,  where  we  observe  a  connection  between  certain 
changes  of  the  fundus  oculi  and  an  internal  disease. 

(«)  Changes  in  the  fundus  oculi  in  nervous  diseases.  All  diseases 
which  lead  to  a  general  increase  of  the  intracranial  pressure  may 
cause  choked  disc  (neuritis  optica).  It  is  then  always  bilateral.  At 
the  same  time  choked  disc  may  be  absent  in  all  these  conditions,  but 
its  presence  is  of  the  highest  diagnostic  significance,  and  particularly 
in  tumors  and  meningitis.  Hydrocephalus  is  more  rarely,  and  abscess 
of  the  brain  very  rarely  combined  with  choked  disc.  Unilateral 
choked  disc  is  only  caused  by  local  pressure  (a  tumor,  etc.)  upon  one 
optic  nerve. 

The  extent  to  which  vision  is  disturbed  when  we  have  choked 
disc  varies  very  much ;  there  may  be  none,  or  almost  none.  Disturb- 
ance of  vision  in  choked  disc  usually  occurs  very  early  and  markedly 
if  the  disease-process  causes  pressure  upon  the  chiasm  or  the  begin- 
ning of  the  optic  nerve,  as  in  tumors  of  the  hypophysis  cerebri,  or  if 


APPENDIX,  601 

there  is  hydrocephalus  which  presses  inward  upon  the  third  ventricle 
(Wernicke).  There  must,  of  course,  be  disturbance  of  vision  if  the 
choked  disc  is  followed  by  atrophy. 

Pronounced  choked  disc  is  very  easily  recognized  (only  take  care : 
neuro-retinitis  Brightii  is  exceptionally  very  much  like  it) ;  but  the 
exact  recognition  of  a  slight  neuritis  optica  is  very  difficult.  When- 
ever there  is  such  a  possibility  an  ophthalmologist  should  always  be 
called  in. 

It  seems  that  neuro-retinitis  is  particularly  apt  to  be  present  in 
meningitis  when  there  is  a  basilar  exudation.  Neuro-retinitis  is  said 
to  occur  also  with  encephalitis. 

Primary  atrophy  of  the  optic  nerve  takes  place  (by  the  intraocular 
portion  of  the  nerve  changing  into  a  white  disc  with  a  sharp  boundary) 
especially  in  tabes,  then  sometimes  in  multiple  sclerosis,  dementia 
paralytica ;  lastly,  it  occurs  from  pressure  upon  the  chiasm.  [The 
capillary  circulation  ceases,  and  hence  the  disappearance  of  the  nor- 
mal rosy  hue.] 

Finally,  it  is  to  be  mentioned  that  retinal  apoplexy  has  been 
observed  as  the  forerunner  of  cerebral  hemorrhage,  emboli  of  the  cen- 
tral retinal  artery  as  the  precursor  of  cerebral  embolism.  Regarding 
the  changes  of  the  fundus  oculi  in  syphilis,  see  below. 

We  hardly  ever  find  choroidal  tubercle  in  tubercular  meningitis. 
(But  with  reference  to  acute  general  milliary  tuberculosis,  see  below.) 

(h)  Changes  in  the  fundus  oculi  in  other  internal  diseases. 
Betinitis  or  neuro-retinitis  albuminurica,  with  white  specks,  often 
arranged  as  radiating  lines  around  the  macula,  sometimes  confluent, 
thickening  of  the  walls  of  the  vessels  and  hemorrhages,  occurs  partic- 
ularly frequently  in  contracted  kidney,  also  often  in  subchronic  and 
chronic  nephritis,  but  very  seldom  in  acute  nephritis.  The  dis- 
turbance of  vision  is  greater  or  less  according  as  the  macula  is 
attacked  or  not.  Ursemic  amaurosis  has  nothing  to  do  with  this  con- 
dition, but  as  a  matter  of  fact  this  form  of  retinitis  often  occurs  in 
uraemia  (and  this  is  important  for  the  diagnosis). 

In  constitutional  syphilis  (hence  also  in  syphilis  of  the  brain)  we 
sometimes  observe  syphilitic  changes  in  the  fundus  oculi :  retinitis 
syphilitica,  retinitis  pigmentosa,  choroiditis  syphilitica. 

We  not  infrequently  find  tubercle  of  the  choroid  in  acute  general 


602  ■  APPENDIX. 

tuberculosis,  especially  in  the  region  of  the  macula ;  the  tubercular 
deposits  are  generally  very  difficult  to  see. 

In  diabetes  there  occurs  a  peculiar  so-called  diabetic  neuro-retinitis 
and  atrophy ;  in  leucaemia,  hemorrhages  and  whitish  exudate ;  in  per- 
nicious anaemia,  but  also  in  simple,  severe  anaemia,  hemorrhages 
(generally  easily  seen). 

Further,  retinal  hemorrhages  are  not  unimportant  diagnostic  signs 
of  pyaemia,  particularly  pyaemic  endocarditis.  They  are  not  an  abso- 
lutely fatal  sign,  as  I  myself  saw  in  one  case  of  puerperal  pyaemia : 
this  undoubted  case  of  pyaemia,  where  besides  the  hemorrhages  there 
were  chills  and  slight  icterus,  recovered  and  the  effused  blood  disap- 
peared, leaving  clear  specks  behind. 

We  have  still  to  mention : 

Pulsation  of  the  retinal  arteries  in  aortic  insufficiency,  embolus  of 
the  central  artery  in  endocarditis  (also  frequently  observed  in  chorea); 
lastly,  after  severe  hemorrhages  (particularly  of  the  stomach,  also  of 
the  intestine,  and  uterus)  there  occurs  sudden  amaurosis,  not  infre- 
quently at  first  without  any  ophthalmoscopic  condition,  afterward 
usually  with  distinct  atrophy  of  the  optic  nerve. 

Alcoholic  amblyopia  shows  a  negative  condition,  or  else  hyperaemia, 
neuritis,  atrophy  ;  tobacco  amblyopia  shows  a  normal  fundus  optica,  or 
atrophy  ;  in  amblyopia  or  amaurosis  saturnina  either  there  is  nothing, 
or  else  there  is  hyperaemia  and  neuritic  atrophy. 

3.  Bacteria  which  come  under  Consideration  in  the  Diagnosis 
of  Internal  Diseases. 

The  object  of  the  following  sections  is  to  summarize  the  notable 
peculiarities  of  the  different  microorganisms  which  have  already  been 
mentioned  in  different  parts  of  the  work.  But  this  pertains  not  only 
to  the  characteristics  of  the  different  organisms  and  their  appearances 
when  stained,  but  also  to  the  much  more  important  phenomena  of  their 
growth  in  cultures  and  under  animal  experimentation.  In  regard  to 
the  methods  of  procedure  we  must  refer  to  the  text-books  upon  bac- 
teriology, and  particularly  to  the  instruction  in  the  bacteriological 
courses. 

Staphylococcus  pyogenes  consists  of  small  round  cells  which  are  usu- 
ally found  in  irregular  masses,  but  are  never  arranged  in  chains.    The 


APPENDIX.  .  603 

spores  of  this,  as  of  all  other  micrococci,  have  not  yet  been  discovered. 
It  grows  upon  gelatin  even  without  much  air,  in  the  temperature  of  the 
room,  still  more  rapidly  and  luxuriantly  in  a  higher  temperature. 
The  gelatin  becomes  liquefied.  Scratch  cultures  are  either  gold- 
yellow  (Staph,  pyogen,  aureus),  or  white  (Staph,  pyogen.  albus),  or 
clear  yellow  (cereus),  or  citron  yellow  (citreus).  Upon  a  surface  it 
gi-ows  in  round,  light-brownish  colonies  looking  like  dots,  which  lose 
their  sharp  contour  in  the  centre  of  the  fluid.  Mice,  guinea-pigs, 
and  rabbits  die  in  from  two  to  nine  days  after  intravenous  and  peri- 
toneal injections.  Mice  are  killed  with  certainty  only  after  the  sub- 
cutaneous injection  of  a  large  amount,  but  none  of  the  other  animals 
named  are  killed  by  subcutaneous  inoculation. 

It  can  be  stained  by  all  of  the  aniline  stains,  also  by  Gram's 
method.  It  is  the  most  common  excitor  of  suppuration.  It  is  found 
in  abscesses,  furuncles,  in  many  cases  of  empysema,  purulent  perito- 
nitis ;  also  in  ulcerative  endocarditis,  etc.,  upon  the  valves  of  the 
heart;  in  pyaemia  and  acute  osteo-myelitis,  in  the  suppuration 
which  complicates  typhoid  fever,  etc. 

Streptococcus  pyogenes^  resembling  the  first  named  by  its  round 
cells,  forms  chains  by  progressive  portions  pushing  out  in  the  same 
direction,  which  sometimes  twist  around  each  other.  The  separate 
ones  often  vary  in  size.  It  grows  slowly  upon  gelatin,  better  upon 
agar,  in  the  temperature  of  the  room,  but  more  rapidly  in  an  incuba- 
tor at  a  temperature  of  27°  C.  [=98.6  F.].  It  does  not  render  gelatin 
fluid.  The  cultures  upon  a  plate  are  extremely  small,  \  mm.  diameter, 
yellowish  to  yellowish-brown  in  color.  When  inoculated  by  puncture 
it  develops  slowly  and  does  not  spread  out  upon  the  surface  of  gelatin. 
It  is  stained  like  the  preceding.  It  is  fatal  to  animals  only  when  they 
have  been  previously  weakened ;  it  causes  redness  and  swelling  of  the 
rabbit's  ear.  There  is  frequently  found  a  pus  coccus  which  particu- 
larly inhabits  the  lymph  tracts,  and  causes  progressive  phlegmon ;  it 
is  also  found  in  pysemia,  especially  puerperal  pyaemia,  likewise  fre- 
quently in  endocarditis. 

Streptococcus  erysipelatosus,  morphologically  and  as  regards  its 
staining  qualities,  is  like  the  preceding,  but  from  the  culture  has  thus 
far  not  with  certainty  been  distinguished  from  it.  In  the  rabbit's 
ear  it  causes  a  somewhat  less  active  and  extensive  inflammation  than 


604  APPENDIX. 

the  streptococcus  pyogenes.  The  inflammation  has  the  symptoms  of 
erysipelas. 

Micrococcus  gonorrhoeus  (gonococcus,  compare  Fig.  131,  p.  427) 
usually  occurs  in  the  form  of  diplococci  (roll-form),  which  often  appear 
as  tetracocci  in  that  the  single  coccus  has  a  bright  stripe,  as  the 
beginning  of  a  new  portion.  It  is  difficult  to  breed,  but  is  best  done 
upon  coagulated  blood-serum,  in  a  moist  room  at  32°  C.  [=  90°  F.] 
(Bumm).  It  is  stained  with  all  of  the  aniline  dyes,  best  with  a  con- 
centrated watery  solution  of  methylene-blue,  stained  after  the  method 
of  Grram.  It  seems  that  it  is  pathognomonic  of  gonorrhoea  if  found 
within  the  pus-corpuscles.  Outside  of  the  pus-corpuscles,  and  even 
in  epithelial  cells,  there  also  occur  other  diplococci  of  like  form  and 
staining  qualities. 

Bacillus  anthracis  (see  Fig.  78,  p.  280)  is  a  rod,  on  an  average 
about  5-10^  long,  1-1.25/z  wide,  with  an  abrupt  end,  often  some- 
what concave,  with  the  inclination  to  develop  into  threads,  without 
peculiar  motion.  It  develops  upon  gelatin,  potatoes,  in  alkaline  urine 
at  the  ordinary  temperature  of  the  room,  better  at  36°  C.  [=  97°  F.]. 
Sometimes  there  develop  spores  within  spores  (endogenous  formation 
of  spores).  Gelatin  is  rendered  fluid ;  when  the  amount  of  air  is 
limited  it  develops  poorly.  Plate-cultures,  after  twenty-four  hours, 
can  be  seen,  when  slightly  magnified,  as  round  grayish-black  spots,  or 
wavy,  as  if  curled ;  upon  potatoes  the  cultures  are  gray- white,  some- 
what elevated.  It  is  fatal  to  susceptible  nursing  animals  (mice,  rabbits, 
guinea-pigs,  certain  kinds  of  sheep),  even  with  the  most  minute  inocu- 
lation and  in  a  very  short  time.  They  are  found  in  capillary  blood 
and  in  all  organs  richly  supplied  with  blood,  particularly  the  spleen ; 
with  living  bodies  they  do  not  develop  spores,  likewise  usually  no 
long  threads.  They  are  stained  by  all  basic  aniline  coloring-matters, 
but  they  are  easily  spoiled  if  the  covering-glass  is  made  too  hot ;  they 
become  non-transparent  if  too  strongly  stained.  They  can  also  be 
stained  by  Gram's  method. 

Bacilli  of  malignant  oedema  are  3— 3.5m  long,  1—1. 1^  wide  (Fliigge), 
hence  thinner  and  shorter  than  the  anthrax  bacilli,  from  which  they 
are  also  distinguished  by  the  rounded  ends.  They  form  rigid  threads, 
often  of  considerable  length.  The  individual  bacillus  forms  spores, 
and  these  are  so  large  that  they  distend  the  bacillus.  In  the 
dependent  drops  they  manifest  peculiar  motions.     They  only  grow 


APPENDIX.  605 

^vhen  oxygen  is  excluded,  hence  are  anserobia.  They  develop  in  a 
reagent  glass,  best  in  gelatin  to  which  is  added  a  ^  per  cent,  solu- 
tion of  grape  sugar  (Fliigge).  They  flourish  best  at  the  temperature 
of  the  body.  But  they  only  grow  at  the  lower  end  of  a  deep,  very 
fine  canal  formed  by  sticking  in  a  needle,  and  this  canal  is  to  be 
again  closed.  It  fluidizes  the  gelatin  and  forms  an  oiFensive-smelling 
gas.  It  is  stained  by  all  the  aniline  dyes,  but  poorly  after  the  Gram 
method.  It  is  found  in  garden  soil,  in  muddy  water,  in  the  blood  of 
asphyxiated  animals,  etc.  A  little  of  the  soil  taken  up  on  the  point 
of  a  penknife  and  put  under  the  skin  of  the  abdomen  of  a  guinea-pig 
or  rabbit  generally  kills  it  by  the  invasion  of  the  bacilli  in  one  to  two 
days  (but  sometimes,  during  this  experiment,  tetanus  develops).  In 
man  it  causes  oedema  and  sometimes  emphysema  of  the  skin  (see  p.  55). 

Tyjphus  ahdominalis  bacilli  (see  Fig.  121,  p.  391)  are  short,  slender 
rods  with  rounded  ends,  thrice  as  long  as  broad,  one-third  as  long  as  the 
diameter  of  a  red  blood-corpuscle.  They  have  active  motions  (hanging 
drops).  They  form  threads  in  cultures  and  hanging  drops,  but  not  in 
living  animal  bodies.  It  is  questionable  whether  they  form  spores. 
They  develop,  at  the  temperature  of  the  room,  upon  gelatin,  agar, 
potatoes,  without  the  character  of  the  growth  being  characteristic. 
On  the  other  hand,  the  potato  culture  is  characteristic :  for  some  days 
after  the  inoculation  it  would  seem  as  if  nothing  had  grown — at  most 
that  the  surface  of  the  potato  around  the  inoculating  scratches  has  a 
moist  shimmer ;  in  the  whole  circumference  of  this  shimmer  a  very 
thick  resisting  turf  of  bacilli  is  present.  But  this  peculiarity  of  be- 
havior is  not  always  manifest.  Upon  some  potatoes  it  is  not  visible. 
Only  that  culture  in  which  it  is  visible  is  demonstrative.  It  is  best 
stained  with  carbol-fuchsine  or  Loffler's  alkaline  methylene- blue  solu- 
tion ;^  it  is  be  washed  only  with  water.  It  is  stained  after  Gram's 
method.  It  regularly  occurs  in  the  intestine,  spleen,  liver,  kidneys, 
also  in  the  stools,  and  now  and  then  in  the  blood  in  abdominal  typhus 
[typhoid  fever]. 

Tubercle  bacilli  (compare  Fig.  40,  p.  184,  and  Fig.  130,  p.  426) 
are  thin  rods,  1.5— 3. 5/^  long  (Fliigge),  frequently  slightly  curved  or 
somewhat  broken ;  they  often  form  threads,  and  sometimes  two  or 

1  30  e.em.  of  concentrated  alcoholic  solution  of  methylene-blue,  100  c.cm.  of  one  per 
cent,  solution  of  potassium. 


506  APPENDIX. 

more  lie  close  together.  Very  often  they  contain  a  number  of  egg- 
shaped  spaces  (spores),  and  then,  when  stained  and  slightly  magnified, 
they  sometimes  look  like  chain  micrococci.  They  have  no  inde- 
pendent motion.  They  grow  best  in  a  reagent  glass  upon  an  oblique 
coagulated,  sterilized  blood-serum  and  glycerin-agar,  at  a  tempera- 
ture of  37.5°  C.  (min.  30,  max.  42).  At  beSt  they  grow  very 
slowly,  and  hence  the  strictest  care  is  necessary  that  it  may  not  de- 
velop excessively.  (For  the  technique,  see  special  works.)  In  four- 
teen days  there  appear  small,  dull-white  scales  and  specks,  which, 
when  slightly  magnified,  show  an  arrangement  that  reminds  one  of  a 
tangled  braid  of  hair  (compare  Fig.  130,  p.  426).  We  can  have  it 
develop  upon  a  covering-glass  and  then  stain  it  by  the  method 
described  on  page  185.  The  experiment  of  inoculation  is  best  made 
upon  guinea-pigs,  by  placing  some  sputum,  for  instance,  in  the  abdom- 
inal cavity.  Generally,  there  is  no  reaction  in  the  peritoneum.  'After 
two  to  three  weeks  the  glands  swell,  and  in  four  to  eight  weeks  the 
animal  dies. 

Lepra  hacilli,  resembling  small  tubercle  bacilli,  are  stained  with 
aniline  in  the  usual  way,  but  also  like  tubercle  bacilli ;  hence,  like  the 
former,  there  may  be  a  double  staining.  They  are  found  in.  leprous 
skin,  in  the  glands,  in  the  tissue-juices,  in  the  nerves,  also  said  to  be 
found  in  the  blood,  etc.,  mostly  in  small  and  large  cells  resembling 
giant-cells.     Cultures  have  not  yet  been  successfully  made. 

Anthrax  hacilli  are  like  tubercle  bacilli,  only  somewhat  broader. 
They  are  stained  with  Loffler's  potassic  methylene-blue.  Stain  very 
carefully,  then  wash  with  dilute  acetic  acid.  They  are  often  easier 
and  more  certainly  demonstrated  by  culture  than  by  animal  experi- 
mentation. They  develop  rapidly  upon  slices  of  potato  at  85°  C. 
[=  97°  F.],  as  a  brownish,  slimy  mass.  It  can  be  inoculated  upon 
guinea-pigs ;  some  maintain  that  puppies  are  better.  Death  follows 
after  an  indefinite  time,  and  nodules  occur  in  various  organs  (one  of 
the  first  symptoms  is  a  swelling  of  the  testicles). 

The  cholera  bacillus  (see  Figs.  117,  118,  p.  889,  and  Fig.  119, 
p.  390)  has  been  very  fully  described  upon  p.  389f.  It  has  there 
been  pointed  out  that  the  certain  proof  is  only  made  by  culture. 
A  mucous  floccule  from  the  stools  or  from  the  linen  is  taken, 
placed  in  a  small  glass  with  a  fluid  five  to  ten  per  cent,  culture- 
gelatin,   from    which    plate    cultures    are  prepared.     After   standing 


APPENDIX.  607 

one  to  two  days  in  an  ordinary  temperature,  small  white  points 
are  seen  at  the  bottom  which  gradually  reach  the  top,  and,  by 
rendering  the  gelatin  fluid,  form  deep,  funnel-like  depressions.  At 
the  bottom  of  the  funnel  lie  the  whitish  cultures,  not  larger  than  a 
pin-head.  By  making  an  inoculation-puncture  in  the  reagent  glass 
there  is  also  produced  a  funnel,  which,  from  the  rapid  thinning  of  the 
fluidized  gelatin,  contains  a  large  bubble  of  air.  The  lower  part  of 
the  inoculation-puncture  I'esembles  a  thin  thread,  which  in  some 
places  is  as  clear  as  glass,  and  looks  like  an  empty  capillary  tube, 
while  in  other  places  the  culture,  sunk  together,  consists  of  gray  and 
whitish  threads.  In  the  dependent  drops  there  is  active  motion, 
like  a  swarm  of  gnats,  and  the  bacilli  strive  to  reach  the  border. 
Larger  plate-cultures,  under  a  slight  magnifying  power,  show  a  pecu- 
liar lustre  and  an  arrangement  as  if  they  were  a  collection  of  shivered 
glass.  The  inoculation  is  made  upon  guinea-pigs,  the  contents  of 
whose  stomach  is  made  alkaline  by  5  c.cm.  of  a  five  per  cent,  solu- 
tion of  soda  (using  an  oesophageal  catheter) ;  the  intestine  is  made 
quiet  by  injecting  into  the  peritoneum  1  c.cm.  tinct.  opium  for  each 
200  grammes  weight  [of  the  animal]  ;  then,  by  means  of  the  oesopha- 
geal catheter,  there  is  introduced  10  c.cm.  of  the  deposit  of  the  cholera 
bacilli  in  bouillon.  After  two  days  the  animal  dies  (often  without 
diarrhoea,  always  without  vomiting) :  the  condition  of  the  intestine  is 
found  to  be  exactly  like  that  in  cholera.  In  the  intestines  are  abun- 
dant cholera  bacilli. 

Bacilli  of  Finhler-Prior  (see  Fig.  120,  p.  391)  resemble  cholera 
bacilli,  but  are  thicker  and  plumper ;  but  in  the  colored  preparations 
they  cannot  certainly  be  distinguished  from  Koch's  comma  bacillus. 
Plate-cultures  develop  remarkably  rapidly,  and  render  gelatin  fluid 
in  much  larger  quantity  than  cholera  bacilli.  This  diff"erence  in  the 
rapidity  of  development  is  the  best  mark  of  distinction.  When  slightly 
magnified,  the  cultures  seem  to  be  very  finely  and  uniformly  granular, 
of  a  yellowish-brown  color.  The  inoculation-puncture,  likewise,  shows 
a  much  more  rapid  fluidization,  but  not  the  clear  threads  beneath  the 
upper  "air-bubble,"  but  an  irregularly  wide  canal,  which  reminds  one 
of  a  stocking.  After  a  week  the  whole  test-tube  becomes  fluid. 
Also,  the  inoculation  of  animals  gives  a  different  result — stinking 
intestinal  contents,  while  in  cholera  they  smell  stale. 


INDEX. 


ABBEE,  reference  to,  185     ' 
Abdomen,  distention  of,  from  in- 
flammatory exudation,  314 
distention  of,  causes  of,  309 
drawing-in  of,  causes  of,  309 
inspection  of,  313 
sound  on  percussing,  109 
topography  of,  297 
tumors  of,  dullness  over,  306 
value    of   measuring    circumfer- 
ences of,  316 
Abdominal  affections,  severe  hiccougli 
in,  540 
breathing  disappears  in  paralysis 

of  diaphragm,  90 
contents,  position  of,  illustrated, 

298 
diseases,  headache  with,  483 
distention,    effect    on    diaphrag- 
matic breathing,  90 
inflammation,    restricting    action 

of  the  diaphragm,  90 
organs,  irritative  cough  from,  165 
pressure,  importance  of,  in  defeca- 
tion, urination,  and  labor,  540 
reflex  defined,  496 

increase  of,  in  intercostal  neu- 
ralgia, 496 
unilateral,  absence  of,  587 
swellings,  solid,  feeling  of  resist- 
ance with,  116 
typhus.     iS'ee  Typhoid  Fever, 
wall  in  emphysema,  84 
Abnormal   constituents  of  urine,  sec- 
tion on,  435-442 
sounds  over  lungs,  125 
Abscess,  deep,  revealed  by  oedema,  54 
due  to  dentition,  286 
irregular    enlargement    of    liver 

from,  322 
large,  peptonuria  with,  439 
of  abdominal  wall,  pain  from,  309 
case  of,  which  simulated 
meteorism,  309 
of  chest,   wall,   weakened   vocal 
fremitus  with,  158 


Abscess  of  liver,  prominences  on  liver 
from,  326 
tenderness  with,  324 
of  lung,  effect  of,  on  thorax,  87 
elastic  threads  in  sputum  of, 

177 
hsematoidin  in  sputum  in,  172 
lung  tissue  in  sputum  in,  172 
purulent  sputum  in,  169 
of  spleen,   unequal   enlargement 

with,  335 
of  tonsil,  290 
perinephritic,   cause    of    pus    in 

urine,  419 
retro-pharyngeal,  cause  of  cyan- 
osis, 43 
Abscesses,    staphvlococcus    pyogenes 

found  in,  603 
Absolute  deadness,  108 
Abulia  defined,  472 
Accidental  murmurs,  229 
Accommodation  in  breathing,  95 
of  valvular  deficiency,  195 
paralysis  of,  563,  568 
Acetic  acid,  excess    of,   in   stomach, 

345 
Acetone,  a  product  of  decomposition 
of  albumin,  449 
diaceturia  with,  447 
odor  of  breath  in  diabetes,  285 

of  urine  from,  414 
source  of,  in  urine,  449 
test  for,  414,  449 
when  occurs,  414 
Acetonuria,  test  for,  448 

when  occurs,  448 
Acholic  stools,  color  of,  373 

odor  of,  371 
Achorion  Sehonleinii,  in  vomit,  366 
Achroodextrin,  from  starch,  353 
"  Acid  curve  "  of  urine  in  twenty-four 
hours,  404 
intoxication  in  diabetic  coma,  449 
reaction  of  urine,  usual,  403 
urine,  calculi  found  in,  433 
Acids,  fatty,  needles  of,  in  sputum,  180 
39  ( 609 ) 


610 


INDEX. 


Acids,  salivation  caused  by,  289 
Acoustic  amnesia,  552 
ganglion,  461 
nerve,  551 

disease  of,  572 
injury  of,  572 
^Acromegalia,  defined,  583 
Actinomyces  in  pleural  exudation,  161 
in  sputum,  175 

described,  189 
with  inflammation  of  mouth,  290 
Acuoxylon,  140 

Acute  diseases  not  recurrent,  22 
Adaptation  in  breathing,  95 
Addison's  disease  described,  48 
-i^gophony  described,  159 
jEsthesiometers,  Sieveking's,  use   of, 

474 
After-sensibility,  defined,  478 
Age,  location  of  heart  in,  192 

lung  boundary  differences  due  to, 

125 
old,  area  of  heart  dulness  in,  205 
position  of  apex  beat  in,  198 
variations  of  percussion  note  by, 
120 
of  pulse  affected  by,  234 
Aged,  venous  thrombosis  in  marasmus 

of  the,  268 
Ageusis,  with  'total  hemiansesthesia, 

574 
Agrammatismus  defined,  561 
Agraphia,  552,  553 

amnesia  may  simulate,  556 
an  aphasic  symptom,  561 
Air  in  peritoneal  cavity,  auscultation 
and  percussion  of,  318 
in  peritoneum,  a  cause  of  dimin- 
ished area  of  liver-dulness,  331 
-passages,  stenosis  of  inspiratory 

pressure  diminished  in,  164 
sound  of,  on  percussing  over  cavity 
containing,  109 
Akataphasia  defined,  561 
Albumin,  acetone   a   product   of  de- 
composition of,  449 
boiling  and  nitric  acid  test,  436 
-curve,  437 

decomposition  of,  leucin  and  tyro- 
sin  products  of  432 
ferrocyanide  of  potassium  test,  436 
Geisler's  test  papers,  436 
in  pleund  fluid,  160 
in  serous  sputum,  169 
in  sputum,  190 
in  urine,  435,  439 


Albumin  in  urine  after  exertion,  437 
makes  the   bismuth  test  for 

sugar  uncertain,  444 
significance  of  according  to 
amount,  420 
must  be  removed  in  determining 

nitrogen  and  urea,  434 
physiological,    small    amount  in 

urine,  405 
picric  acid  test,  436 
qualitative  tests  for,  435 
quantitative  tests  for,  437 
rare  forms  of,  489 
Albuminous     bodies,     digestion     of, 

345 
Albuminuria,  a  cause  of  dropsy,  53 
casts     scanty    in     physiological, 

422 
cyclic,  435,  437 
oedema  with,  54 
renal   casts   in  urine,  diagnostic 

value  of,  422 
retinitis  with,  described,  601 
when  occurs,  435 
Alcohol   amblyopia,  central  scotoma 
in,  569 
formation  of,  in  stomach,  345 
headache  in  poisoning  with,  483 
paralysis,  lessened  excitability  in, 

without  EaR  in,  525 
poisoning,  odor  of  breath  in,  285 
uses  of  effect  on  disease,  21 
Alcoholic  amblyopia,  602 

poisoning,  delirium  tremens  from, 

471 
tremor,  531 
Alcoholism,  trembling  of  tongue  of, 
_  287  _ 

lipseraia  in,  280 
Alderton,  reference  to,  199 
Alexia,  552 

Alkalies,  salivation  caused  by,  289 
Alkaline  fermentation  in  urine,  from 
micrococci  and  bacilli, 
425 
odor  of,  404 
turbid  urine  from,  412 
reaction   of  urine,  sometimes  in 

health,  403 
urine,  simple,  distinguished  from 
urine  alkaline  from   fermenta- 
tion, 426 
Allochiria  defined,  478 
Amaurosis  after  severe  hemorrhages, 
602 
saturnina,  602 


INDEX. 


611 


Amaurosis,  temporary  partial,  signifi- 
cance of,  571 
ursemic,  601 
with  albuminuria,  441 
Amblyopia,  alcohol,  569 

alcoholic,  and  tobacco,  602 
Ammoniacal  fermentation  of  urine,402 

odor  of  stool  from  urine,  372 
Ammoniaco-magnesian  phosphate  in 

urine  described,  431 
Ammonio-magnesian    phosphates    in 

urine,  402 
Amnesia,  554,  556 

acoustic  and  visual,  552 
may    simulate    atactic    aphasia, 
word-deafness,  word-blindness, 
agraphia,  556 
mixed  with  aphasia,  555 
Amnestic  aphasia,  553,  554 
Amoeba  coli,  391 
Amphoric  breathing,  159 

corresponds    with     metallic 

rales,  153 
defined, 148 

with  cavities  in  lungs,  147 
Amphoteric  reaction  of  urine,  404 
Amyloid   degeneration   of  intestines, 
fats  poorly  absorbed  in,  371 
disease  of  spleen,  335 
kidney,  albuminuria  with,  435 

casts  in  urine  of,  422 
liver,  surface  of,  325 
Amylolysis,  disturbed  in  super- acidity 
of  stomach,  356 
incomplete,  shown  by  microscopi- 
cal examination  of  vomit,  365 
Amylolytic  period  of  digestion,  342, 
343 
shortened,  346 
Amyotrophic  lateral  sclerosis,  580,  586 
EaR  with,  524 
increase  of  tendon  reflex 

in,  500 
lessened     excitability 
without  EaE.  in,  525 
partial  EaR  with,  525 
An,  an  abbreviation  for  anode,  506 
Anaemia,  absence  of  pulse  with,  243 
a  cause  of  dropsy,  53 
albuminuria  with,  435 
alkalescence  of  blood  diminished 

in,  283 
caused  by  anchylostoma  duode- 

nale,  382 
color  of  blood  in  cases  of  severe, 
271 


Anaemia,  diminished  haemoglobin  in, 

275 
dizziness  with,  471 
due  to  bothriocephalus  lata,  380 

to  tapeworm,  377 
headache  with,  483 
•  heart-sounds  often  strengthened 
in,  217 
in  contrast  with  chlorosis  as  re- 
gards  diminution  of  red  cor- 
puscles, 276 
leucocytosis  in,  278 
may  be  concealed  by  redness  of 

face,  42 
microcytes  and  macrocytes  in,  276 
microcythsemia  with,  276 
murmurs  heard  in,  229     ' 
oligocythaemia  in,  but  not  in  chlo- 
rosis, 274 
peculiarities  of  blood  in,  275 
pernicious,  leucin  and  tyrosin  in 
urine  of,  432 
retinal  hemorrhages  in,  562 
uric  acid  increased  in,  434 
poikilocytosis  with,  277 
polyuria  in,  406 

progressive  venous  pulse  with,  268 
red    corpuscles    diminished   and 

paler  in,  275 
retinal  changes  in,  602 
splenic,  enlargement  of  spleen  in, 

335 
stools  to  be  examined  for  parasites 

in,  377 
subacidity  of  stomach  in,  356 
subjective  sensations  of  vision  in, 
571  _  _ 
sensibility  of  hearing  in,  572 
tracing  of  pulse  of,  248 
urine  of,  very  pale,  408 

should  be  examined  for  ba- 
cillus tuberculosis,  426 
venous  humming  in,  269 
vertigo  with,  472 
Anaemic  heart-murmurs,  explanation 
of,  230 
propagated       from      venous 
trunks  in  chest,  269 
murmurs,  229 

necrosis  of  pons  and  medulla,  462 
Anaesthesia,  cause  of,  459 
defined,  477 

important  distinction  with  refer- 
ence to  distribution  of  nerve,  479 
of  dorsum  of  forearm,  caution  re- 
garding, 485 


612 


INDEX. 


Ansestliesia  of  mucous  membrane  in 
hysteria,  497 
partial,  cause  of,  459 
sensory,  in  gross  hysteria,  534 
total,  rare,  479 
Analgesia  defined,  479 
Anamnesis  defined,  17 
mode  of  taking,  19 
scheme  for,  26 

unreliable  regarding  spasms,  533 
what  it  comprises,  19,  20 
Anarthria  defined,  548 
Anasarca.     See  CEdema. 
Anatomical  disease,  symptoms  of,  587 
divisions  of  the  chest,  76 
variations,  cause  of  unequal  pulse 
in  symmetrical  vessels,  257 
Anatomy  of  heart,  191 

of  liver,  819 
Anchylostoma    duodenale,    described 

and  illustrated,  382 
Anchylostomen  in  vomit,  364 
Anchylostomiasis,  382 

feces  of,  contains  Charcot's  crys- 
tals, 388 
Aneurism,    absence  of  pulse   with, 
243 
aortic,  pulsation  in,  204 
blood  in  sputum  from  rupture  of 

167 
caution  regarding,  when  making 

exploratory  puncture,  162 
diflicuity  in  distinguishing  from 
apparent  enlargement  of  heart, 
210 
effect  of,  upon  pulse  in  one  of  two 

symmetrical  vessels,  257 
increased  circumference  of  thorax 

in,  163 
near  oesophagus,  caution  regard- 
ing sounding  oesophagus,  294 
neuralgia  from  pressure  of,  483 
of  abdominal  aorta,  255 
of  aorta,  and  other  arteries,  effect 
on  pulse,  245 
crystals  in  sputum  in  hemor- 
rhage into  lungs,  180 
cyanosis  from,  43 
description  of,  254 
how  distinguished  from  em- 
pyema pulsans,  102 
jjressing  on  the  larynx,  75 
pressure   by,  upon  recurrent 
nerve,  296,  599 
of  arch  of  aorta,  affects  vessels  of 
left  side,  255 


Aneurism  of  ascending  aorta,  affects 
vessels  of  right  side,  254 
of  descending  aorta,  255 
of  innominate  artery,  255 
of  minute  arteries  of  brain  a  cause 

of  hemorrhage,  577 
of  pulmonary  artery,  255 
phenomena  of,  40 
pressing  heart  forward,  203 
pressure  on  nerves  from,  469 
pulsation  of,  near  stomach,  302 
recurrent  paralysis  a  symptom  of, 
_  600 

simulates  enlarged  heart,  209 
systolic  pulsations  at  base  of  heart 
in,  203 
Angina,    cause     of    enlargement    of 
tongue,  286 
hepatica,  herpes  with,  50 
Ludovici,  594 

cause  of  cyanosis,  43 
necrotica,  tonsils  in,  290 
pectoris,  in  organic  disease  of  the 
heart,  577 
pulse  in,  240 
Angle,  epigastric,  82 

in  emphysematous  thorax,  83 
of  Louis,  84 

in  phthisical  thorax,  84 
Angulus  Ludovici  defined,  76,  78,  81, 

82 
Anhidrosis,  sudamina  after  long-con- 
tinued, 50 
Anidrosis,  38,  581 

defined,  37 
Anilin,  color  of  blood  in  poisoning  by, 

270 
Animal  parasites,  examination  of  stool 
for,  377 
exotic,  21 
in  sputum,  182 
in  urine,  section  on,  424 
section  on,  377 
two  found  in  blood,  283 
Ankylostoma,  41 
Ankylostoma-ansemia,  54 
Anodal  closure,  result  of,  506 
Anode,  at  the,  contraction  only  at  the 
opening  of  the  current,  506 
colors  blue  litmus  red,  505 
positive  pole,  504 
Anomalies  of  breathing,  89 
Anorexia,  defined,  472 
Anosmia,  when  it  occurs,  573 

unilateral,  associated  with  hemi- 
ansesthesia,  573 


INDEX. 


Qli 


AnOTe,  occurrence  of,  important  sign 

in  tetanus,  526 
AnSC,  518,  519,  520,  521,523  ^ 

minimal,  determination  of,  515 
Anterior  column  of  spinal  cord,  455 
cranial  fossa,  effect  of  lesion  of, 

457 
gray  columns,  492 

disease    of,    EaR    with, 
524  _ 
horn,  characteristic  sign'  of  cere- 
bral and  spinal   paralysis 
above,  494 
excitability  of,  increases  skin 

reflex,  496 
ganglia,  455,  456,  492 
part  in  skin  reflex,  496 
results  of  disease  of,  490 
horns,  disease    of,  tendon  reflex 
diminished  in,  500 
effect  of  lesion  of,  456 
gray,    EaR   with   lesions  of, 
524 
preside    over    muscular 
tonus,  528 
ofBce  of,  455 
pyramids,  454 
roots  of  spinal  nerves,  455 

compression  of,  results  of,  491 
Anthrax  bacilli,  cultures,  606 
described,  280,  606 
illustration  of,  280 
Antifebrin,  urine  after  taking,  451 
Antiperistalsis  of  stomach,  303 
Antipyrine,  urine  after  taking,  451 
Anuria  from   obstruction   by  echino- 
coccus,  425 
in  acute  nephritis,  407 
in  hysteria,  579 
Anxietv,  effect  of,  on  amount  of  urine, 
401 
pulse  frequent  in,  240 
subjective  expression  of,  in  dys- 
pnoea, 99 
Aorta,  anatomical  relations  of,  254 
aneurism  of,  pulsation  in,  204 
paralysis  of  recurrent  nerve 

by  pressure  from,  538 
pressure  by,  upon  recurrent 
nerve,  296 
relation  of  left  carotid  to,  clinical 

importance  of,  463 
sclerosis   of,    shown   by   stronger 

aortic  second  sound,  217 
stenosis  of,  commencement  of,  ab- 
sence of  apex-beat  in,  202 


Aorta,  stenosis  of,  from  enlarged  retro- 
peritoneal glands,  341 
murmur  of,  where  heard,  224, 

225 
pulse  in,  252 
tracing  of  pulse  in  insufficiency 

and  stenosis  of,  249 
various  phenomena  of,  253 
Aortic    and     tricuspid    insufficiency, 
combined  arterial   and  venous 
crural  sounds  with,  269 
first  sound,    softest  heart  sound, 

217 
insufficiency,  194,  195 

and  stenosis,  effects  of,  195 
opposite     condition      of 
pulse  in,  252 
arterial  liver  pulse  in,  257 
capillary  pulse  in,  256 
double    sound     over    crural 

artery  in,  259 
effect  upon  second  sound,  258 
increased    arterial   pulsation 

with,  257 
murmur  of,  where  heard,  224, 

225 
progressive     venous      pulse 

with,  268 
nulsating  splenic  tumor  with, 

335        _ 
pulsation  in  aorta  with,  254 

of  retinal  arteries  in,  602 
pulse  in,  251 
with,  253 
tracing  of  pulse  of,  249 
weakening   of  first  sound  at 
apex  in,  219 
stenosis,  194 

absence  of  pulse  Avith,  243 
paleness  in,  41 
pulse  with,  242,  244 
sounds  with,  258 
weakening   of  aortic  second 
sound  in,  219 
valve,  insufficiency  of,  sounds  in, 

217 
valves,  where  best  heard,  213,  214 
Ape-hand  in  paralysis,  544 
Apex-beat  of  heart,   examination  of, 
197 
absent  in  pericardial  adhesion,  202 
and    heart-beat    not  to   be   con- 
founded, 201,  203 
causes  of,  198 

change  in  width  and  strength  of, 
200 


614 


INDEX. 


Apex-beat  coincides  with   systole   of 
heart,  212 
displaced   by  retraction  of  lung, 

209 
displacement  of,  199 
doubling  of,  202 

in  determining  apparent  enlarge- 
ment of  heart,  210 
in  dislocation  of  heart,  211 
position  of,  in  children,  198 

Avith    pericardial    exudation, 
202 
strength  and  breadth  of,  a  sign  of 

hypertrophy,  200,  201 
weakening  of,  causes,  201 
Apex,  first  sound  at,  strengthened  in 
mitral  stenosis,  218 
sounds  of  heart  heard  at,  214 
mitral  murmurs  at,  224 
murmur  of  stenosis    of  left 
auriculo-ventricular  open- 
ing, heard  at,  224 
Aphasia,  with  albuminuria,  441 
atactic,  552,  553,  554, 559 
cause  of,  555 
phenomena  of,  558 
Charcot's  diagram  of,  560 
Lichtheim's  diagram  of,  557 
localization  of,  555 
mixed  with  amnesia,  555 
mode  of  procedure  in  testing  for, 

555,  556 
motor,  559 

sensory,  phenomena  of,  558 
Aphasic  disturbances,  549 
Aphonia,  74 

a  result   of  recurrent    paralysis, 

599 
how  caused,  597 
in  paralysis  of  recurrent   nerve, 

538 
tone  of  cough  in,  166 
Aphonic  patients,  159 
Aphthae,  in  vomit,  366 
Apices  of  lungs,  81,  82 
boundaries,  122 
caution  regarding  slight  dead- 
ening over,  126 
cavities  in,  131 
diminished  in  phthisis,  137 
disease  of  both,  comparative 

percussion  in,  125 
dry    rales    with    catarrh    of, 

150 
large  rales  in,  a  sign  of  cavity, 
152 


Apices  of  lungs,  percussion  note  over, 
120 
position  of,  changed  by  dis- 
eased condition  in  neck,  137 
relatively     deadened    sound 

over,  114 
shrunken,    open    tympanitic 

sound  over,  110 
sometimes  enlarged,  136 
systolic   subclavian   murmur 

at,  259 
tuberculosis      of,     increased 
vesicular  breathing  in, 
144 
deadened    sound    with, 

129 
pain  with,  102 
prolonged  expiration  in, 

145 
tympanitic        resonance 
over,  in  beginning,  127 
tympanitic  sound  over,  in  be- 
ginning tuberculosis,  112 
upper  limits  of,  125 
Aplasia  of  lung,  deadened  sound  over, 

114 
Apncea,  92 

contracted  pupils  in,  93 
jerking  of  muscles  in,  93 
Apoplectic  attack,  defined,  585 

habit,  575 
Apoplexy.     See  Cerebral  hemorrhage, 
aphasia  after  an  attack  of,  555 
decubitus  after,  582 
disturbance   of  consciousness  in, 

470 
glocosuria  with,  443 
heart  and  vessels  to  be  examined, 

577 
pulse  in,  245 

syncope  as  a  precursor  of,  471 
tinnitus  aurium  sometimes  a  pre- 
cursor of,  573 
transitory  albuminuria  with,  435 
Arc  de  cercle,  468,  534 
Area  of  heart  dulness,  enlargement  of, 

208 
Areometer,    use    of,   in    determining 

specific  gravity  of  urine,  403 
Arm,  motor  centre  for,  454 
nerves  of,  485 

paralysis  of  the  muscles  of,  542 
points  of  electrical  irritation  upon, 

illustrated,  509,  510 
position  during  electrical  exami- 
nation, 511 


INDEX. 


615 


Arsenic,  poisoning  by,  cause  of  haem- 
ato-jaundice,  47 
-paralysis,     lessened    excitability 
in,  without  EaR,  525 
Arterial    liver-pulse,  when    liver   en- 
larged, 322 
pulse,    propagated    through    the 

capillaries,  268 
sclerosis,  abnormal  pulsations  in 
arteries  in,  256 
condition  of  arteries  in,  256 
gallop  rhythm  of  heart  with, 

221 
pulse  with,  244,  245 
Arteries,  examination  of,  234 
Artery,  basilar,  461 

middle  cerebral,  462 

hemorrhages  and  emboli 

most  frequent  in,  463 
largest  and  most  impor- 
tant of  the  brain,  462 
ophthalmic,  461 

posterior  cerebral,  portion  of  brain 
it  supplies,  462 
communicating,  461 
vertebral,  461 
A.rthritis  deformans,  467,  583 

pain  in  spine  with,  483 
Arthropathia  in  nervous  diseases,  583 
Articular  neuralgia,  484 
Arythm  of  pulse,  241 
Arythmic  breathing,  92 
Ascarides    in    ductus   choledochus,  a 

cause  of  jaundice,  47 
Ascaris   lumbricoides   described,  and 
symptoms  of,  380 
eggs  of,  381 
illustrated,  381 
Ascites,    abdominal    veins     enlarged 
with,  314 
associated  with  cirrhosis  of  liver, 

325,  326 
cause  of  diminished  area  of  liver 

dulness,  331 
caused  by  stasis,  314 
chylous,  318 

defined,  and  diagnosis  of,  313 
due  to  venous  engorgement,  260 
etfect  on  form  of  chest,  86 
emplovment  of  deep  breathing  in, 

323 ' 
may  cause  venous  stasis,  262 
press  diaphragm  up,  322 
tympanitic  sound  with  distention 

of  abdomen  from,  130 
value  of  tapping  for  diagnosis,  318 


Asiatic  cholera :   See  Cholera  Asiatica 
Aspergillus  fumigatus  (mould)  in  spu- 
tum, 175,  190 
Aspermatism,  580 
Asphyxia,  local,  in  neuroses,  577 
Associated    movements   in   paralysis, 

defined,  535 
Asthma,    bronchial,    expiratory    dys- 
pnoea peculiar  to,  99 
rapid  breathing  in,  94 
relation  of  Curschmann's  spi- 
rals to,  180 
casts  in  sputum  of,  173 
cause  of  cyanosis,  43 
Charcot-Leyden's      crvstals     in, 
182 

in  sputum  of  bronchial, 
174 
in- connection  with  disease  of  the 

nose,  575 
oxalate   of   lime  in  sputum   of, 

182 
simulation  of,  19 
spirals  in  sputum  of,  175 
uraemic,  440 
Asymmetry   of   breathing   described, 
91 
of  pulse,  245 
of  skull,  465 
Ataxia  defined, 527 

and  explained,  529 
diflSculty  of  distinguishing,  from 

tremor,  531 
of  upper  extremity,  561 
when  it  occurs,  529 
Ataxic  aphasia,  552,  553 

cause  of,  555 
Atelectasis  in  children,  98 
Atelectatic     ciepitation,    inspiratory, 

defined,  154 
Atheroma  of  aorta,  systolic  murmurs 
with,  254 
of  vessels  a  cause  of  hemorrhage 
of  brain,  576 
Athetosis  defined,  535 
Atonia  in  paralysis,  489 
Atonic  atrophic  paralysis,  494 

paralysis,  494 
Atrophic  paralysis,  490 

fibrillary    contractions    in, 

632 
partial  EaR  in,  525 
two  forms  of,  493 
Atrophy    and    paralysis,   parallelism 
between,  493 
disunion  of,  493 


616 


INDEX. 


Atrophy  defined,  35 

disturbance  of  vision  from,  601 
of  inactivity,  491,  494 
of  muscles,  489 
varieties  of,  490 
Atropine,  effect  of,  on  pupil,  567 

poisoning,  red  skin  in,  41 
Auenbrugger,  reference  to,  104,  105 
Aura,  a  prelude  of  epileptic  convul- 
sion, 532 
Auricle,  its  relation  to  venous  pulse, 
264 
left,  location  of,  191 
right,  location  of,  191 
Auricular  semi-lunar  murmur,  where 

heard,  224 
Auricularis  magnus  nerve  illustrated, 

485 
Auriculo-temporal  nerve,  illustrated, 

485 
Auscultation  of  heart,  211 

points   of   election  for,  213, 
214 
of  intestine,  312 
of  lungs,  138 

to  be  after  percussion,  140 
of  peritoneal  cavity,  318 
of  pulse,  257 
of  stomach,  307 
of  veins,  268 
of  voice,  156 

when  it  may  be  omitted,  158 
of  whispered  voice,  159 
results  of,  in  aneurism  of  aorta, 

254 
value  of,  when  small  surface  of 
lung  is  involved,  126 
Autocthonous   clots,  effect  on  pulse, 

245 
Auto-intoxication, 

by  acetonuria,  448 
by  diaceturia,  448 
Auxiliary  muscles  of  inspiration  and 
expiration,  540 
named,  96 
of  respiration,  aid  in  thoracic 
breathing,  99 
Axillary  lines  defined,  76 
nerves  illustrated,  486 
Azoospermia,  580 


BAAS,  reference  to,  151 
Baccilli,  reference  to,  159 
Bacillus   of  anthrax,  illustrated  and 
described,  280 


Bacillus  described,  cultures  of,  604 
distinguished  from  Koch's  comma 

bacillus,  607 
in  sputum  from  mouth,  188,  289 
in  urine,  425 

resembling  tubercle  bacillus, 
400 
of  Finkler-Prior   described,  cul- 
tures of,  390.  607 
of  glanders,  found  in  blood,  282 
of  malignant  oedema  described, 

604 
of  tuberculosis,  absence  of,  187 
discovery    of,    made    elastic 
threads     in     sputum     less 
valuable,  177 
found  in  blood  (rare),  281 
in  sputum,  175 
in  urine,  sign  of  tuberculosis 
of  urinary  passages,  426 
Back,  nerves  of,  too  deep  for  electrical 

examination,  511 
Bacteria,  casts  of,  in  pyaemia,  424 
found  in  hyaline  casts,  423 
intestinal,    in    stools,    value    of, 

388 
in  urine,  399 

of  nephritis,  427 
section  on  their  diagnostic  value, 

602 
urine  made  cloudy  by,  402 
turbid  from,  413 
Balz,  reference  to,  174,  183 
Bamber,  reference  to,  191 
Band-box  note  with  emphysema,  135 
Barrel-shaped  chest,  83 
Bartels,  reference  to,  395 
Basch,  reference  to,  245 
Basedow's  disease,  blowing  murmurs 
over  lymphatic  glands  in, 
259^ 
heart-beat  in,  201 
hemidrosis  in,  38 
increased   strength  of  heart- 
sounds  in,  216 
palpitation  of  heart  in,  577 
pulse  in,  240 
tremor  of,  531 
Basilar  artery,  461 

Baths,  cold,  value  of  pulse  in  showing 
result  of,  253 
induce  perspiration,  37 
Baumann,  reference  to,  432 
Berger,  reference  to,  190 
/3-oxybuteric  acid  in  urine  of  diabetic 
coma,  449 


INDEX. 


61T 


Biceps  reflex,  499 

-teudou  reflex,  498 
Biedert,  reference  to,  164,  186 
Bienstock,  reference  to,  388 
Biermer,  reference  to,  104,  135,  136 
Bile-acids  in    urine,  diagnostic  value 
of,  443 
small   amount  of,  in  normal 

urine,  405 
value  of,  in  jaundice,  46 
coloring  matter  of,  in  urine,  410 
deficiency  of,  effect  on  absorption 

of  fat,  371 
effect  of,  on  color  of  stools,  373 
not  usually  found  in  watery  stools, 

374 
-pigment  in  sputum  in  icterus,  172 
-pigments  and  bile  acids,  section 

on  tests  for,  in  urine,  442 
vomiting  of,  361 
Biliary  colic,  vomiting  in,  358 

engorgement,  tenderness  with,324 
Bilirubin,  46 

Bismuth  test  for  sugar  in  urine,  444 
uncertain  if  there  is  albumin, 
444 
Bizzozero,  reference  to,  271 
Black  color  of  vomit,  from  ingestion 
of  iron,  and  in  acute  lead-poisoning, 
360 
Bladder,    alkaline     fermentation    in, 
cause  of  turbid  urine,  412,  413 
carcinoma  villosum  of,  particles  of 

tissue  in  urine  from,  421 
completely  emptied  by  act  of  uri- 
nation, 408 
crises  (painful  tenesmus)  in  tabes, 

580 
depot  of  pus  in  the  neighborhood 
of,  cause  of  hydrothionic  urine, 
415 
distended,  diagnosis  of,  398 
disturbance  of,  587 
examination  of,  398 
importance  of  emptying  in  exam- 

ing  abdominal  organs,  341 
paralysis  of,  590 
position  of,  398 
retention  of  urine  in,  a  cause  of 

diminution  of  secretion,  408 
tenesmus  of,  causes  of,  400 
Blindness,  central,  568 

result  of  lesion  of  corpora  quadri- 
gemina,  570 
Blood,  abnormal  additions  to,  280 

alkalescence  of  freshly  drawn,  283 


Blood,  arterial,  brighter  in  color  than 
venous,  270 
bacillus   of  typhoid  fever  found 

in,  281 
-casts  in  urine,  sign  of  renal  hsema- 

turia,  424 
chemical  examination  of,  283 
color  of,  in  cases  of  poisoning  by 

various  substances,  270 
coloring  matter  of,  in  urine,  when 

occurs,  410,  441 
corpuscles,  change   in   form   and 
size  of  red,  in  anaemia,  275 
counting  of,  274 
destruction  of  in  intermittent 

fever,  434 
in  stools,  387 
normal    proportion  of  white 

to  red,  278 
pathological    diminution    of 

red,  275 
proportion    of  white  to   red 

increased  in  anaemia,  275 
red,    number    of,  in   a  cubic 
millimetre  of  blood,  275 
crystals  in,  in  leukaemia,  279 
diseases  of,  cause  of  paleness,  40 
entire  amount  equals  about  one- 
thirteenth  weisrht  of  body,  270 
examination  of,  270 
from   nose  and  throat,  diagnosis 

of,  171 
in  sputum  from  rupture  of  aneu- 
rism, 167 
intensity  of  color  of,  270 
in  urine,  form  and  appearance  of, 
412,  416 
causes  albuminuria,  435 
-jaundice,  46 
large    effusions    of,    urobilin    in 

urine  with,  409 
-making    organs,  development  of 

fat  in  disease  of,  41 
microscopical  examination  of,  273 
mode  of  examination  of,  for  micro- 
organisms, 282 
morphological  constituents  of,  im- 
portance of,  in  diagnosis,  270 
movement  of,  in  heart,  193 
murmurs,  229 
normal  structures  of,  273 
pathological  conditions  of,  as  re- 
vealed by  the  microscope,  273 
-pressure,  diminished  amount  of 
urine  when  reduced,  407 
how  measured,  245 


618 


INDEX. 


Blood,  pure,  changed  by  gastric  juice 
in  stomach,  362 
seldom  vomited,  362 
spectroscopic  condition  of,  272 
examination    of,  valuable  in 
three  classes  of  cases,  272 
time  it  takes   to  coagulate  after 

withdrawn,  283 
tracing  of  pulse  after  loss  of,  248 
Bloody  sputum  described,  169 
vomit  (hseoiatemesis),  361 
Blushing,  42 
Boas's  test  for  free  muriatic  acid,  351, 

367 
Boiling  and  nitric  acid  test  for  albu- 
min in  urine,  436 
Boilliau'l,  reference  to,  552 
Bone  reflexes,  500 

Bones  and  joints  in  nervous  diseases, 
section  on,  583 
arrest  of  growth  of,  in  paralysis, 

583 
sound  on  percussion  of,  109 
Borborygmi,  312 
Border  of  lungs,  abnormal  position  of, 

125 
Bornhardt,  reference  to.  35 
Bothriocephalus  lata  described,  379 

illustrated,  379 
Bottcher,  reference  to,  503 
Boulimia  defined,  472 
Boundaries  of  lungs  changed,  136 

method  of  determining,  117, 
119 
parietal,  of  organs,  116 

of  liver,  spleen,- and  kidneys 
illustrated,  321 
Bowels,  disturbance   of,  from  venous 
engorgement,  261 
obstruction     of,    peculiar    grass- 
green  vomit  with,  361 
vomiting  of  feces  in  occlusion  of, 
364 
Brachial  plexus,  Erb's  point,  510 

paralysis  of,  cause  of  anaes- 
thesia of  the  region  of  the 
median  nerve,  487 
Brachycardia,  238 
Brachycephalus,  465 
Brain,  abscess  of,  from  disease  of  the 
nose,  576 
hearing  in,  572 
relation  of,  to  disease  of  the 

lungs,  576 
sensibility  of  cranium  to  pres- 
sure with,  466 


Brain,  absence  of  cough  in  disease  of, 
165 

aneurism  of  minute  arteries  of,  a 
cause  of  hemorrhage,  577 

bloodvessels  supplying,  section  on, 
461-463 

concussion  of,  glycosuria  after,  443 

cysticerci  in,  from  taenia  solium, 
578 

difficulty  of  local  examination  of, 
463 

diseases  of,  anomalies  of  breath- 
ing in,  91 
dyspnoea  in,  94 
headache  with,  482 
inherited,  20 

disturbance  of  vision  by  lesion  at 
base  of,  460 

effect  of  local  disease  at  base  of. 
457 

habit  which  predisposes  to  hemor- 
rhage of,  575 

hearing  in  local  disease  of,  572 

hemorrhage  and  softening  of,  re- 
lation to  diseases  of  the  heart, 
576 

inequality  of  pupils  in  unilateral 
atfections  of,  567 

lateral  view  of,  452 

lesion  at  base  of,  paralysis  of  mus- 
cles of  one  eye  in,  565 

local  diseases  of,  diagnosis  of,  586 
hemidrosis  in,  38 
thrombosis  of  vessels  of,  576 

paralysis  of  cortex  of,  early  spasms 
in,  494 

postures  assumed  in  diseases  of, 33 

retinitis  in  syphilis  of,  562 

slight  amount  of  vomit  in  diseases 
of,  360 

slow  pulse  in  diseases  of,  237 

symptomatic  epilepsy  in  anatom- 
ical diseases  of,  533 

symptoms,  general,  enumerated, 
585      _ 

syncope  in  chronic  diseases  of,  471 

syphilis  of,  changes  in  fundus 
oculi  in,  601 

tuberculous  nature  of  diseases  of, 
if  nutrition  is  poor,  575 

tumors    of    disturbance   of   con- 
sciousness with,  471 
migraine  with,  483 
vertigo  with,  472 

value  of  pulse  in  showing  com- 
plicating disease  of,  253 


INDEX. 


619 


Brain,  vomiting  from  irritation  of,  358 
in  rapidly  developing  diseases 

of,  578 
occurs  suddenly  in  diseases  of, 
359 
Breath,  odor  of,  importance  of,  285 
short,  in  deformity  of  chest,  88 
Breathing.  See  also  under  Respiration, 
abdominal,  90 

disappears    in    paralysis     of 
diaphragm,  90 
anomalies  ot,  89,  91 

from  CO2  in  blood,  92 
asymmetry  of,  described,  91 
costal  type  of,  in  women,  90 
deep,  during  auscultation,  141 
diaphragmatic,   interfered   with, 

86 
irregularity  of,  92 
obstructed,  74 

of  compression  defined,  147 
painful,    effect  of  posture  upon, 

32 
thoracic,  replaced   by   diaphrag- 
matic, 90 
transition,  explained,  149 
undefined,  explained,  148 
Brenner,  reference  to,  572 
Brick-dust     sediment     in    urine    ex- 
plained, 402,  429,  430 
Brieger,  reference  to,  356,  372,  432 
Bright's    disease,    choked   disc   with, 
601 
dropsy  of,  explained,  440 
Broca,  reference  to,  552,  553,  555 
Bromine,  urine  after  taking,  450 
Bronchi,  epithelium  in  sputum  from, 

176 
Bronchial  asthma,  casts  in  sputum  of, 
173 
Charcot-Leyden's  crystals  in 

sputum  of,  174,  182 
relation      of     Curschmann's 
spiral  to,  180 
breathing,  how  conducted  to  the 
ear,  143 
difficult  to  distinguish  from 
vesicular,  143 
normal,  described,  141 
nottobe  confounded 
with  pathological, 
141 
pathological,  explained, 
164 
difficulty  of,  weakened  in  case 
of  filled  cavity,  147 


Bronchial  catarrh,  94 

cause  of  diminished  vesicular 

breathing,  145 
kind  of  rales  with,  150 
tubes,  closure  of,  weakened  vocal 
fremitus  with,  158 
pieces  of,  in  sputum,  172 
rapid   breathing  in  diseases 

of.  94 
sensitiveness  of,   a   cause  of 
cough,  165 
Bronchiectasis,  131 

amount  of  expectoration  in,  168 
friction  sounds  with.  156 
odor  of  sputum  in,  171 
Bronchiectatic  cavities,  micrococci  in 
sputum  from,  189 
ringing  rales  with,  153 
Bronchitis,  acute,  mucus  in  first  stage 
of,  168 
a  ferment  in  sputum  of,  190 
alveolar  epithelium  in  sputum  of, 

177 
amount  of  expectoration  in,  168 
capillary  in  children,  98 
caused  by  dust,  21 
Charcot  Leyden's  crystals  in  spu- 
tum of,  174,  182 
chronic,  morning  cough  of,  165 
cyanosis  in,  43 
diffused,  rales  with,  150 
fetid,  crystals  in  sputum  of,  181 
micrococci  in  sputum  in,  189 
odor  of  sputum  in,  171 
relation  of,  to  brain  disease, 

576 
sputum    in  three   layers   in, 
169,  174 
fibrinous  tubes  iii  sputum  of  acute 

and  clironic  croupous,  172 
increased  vesioular  breathing  in, 

144 
jerking,  inspiration  in,  145 
metallic  rales  with,  150 
non  ringing     rales     with,     when 
there  is  a  broncho-pneumonic 
deposit,  153 
prolonged  expiration  in,  145 
purulent,    coin-shaped  sputa  in, 

169 
putrid,  leptothrix  buccalis  in  spu- 
tum of,  184 
tyrosin  in  sputum  of  fetid,  182 
vital  capacity  of  lungs  in,  164 
Bronchophony  described.  158 
Broncho-pneumonia  in  children,  98 


620 


INDEX. 


Bronchus,  primary,  when  open  tym- 
panitic sound  is  heard  over,  111 
stenosis  of,  98 
Bronze  skin,  48 
Bruit  de  pot  fele  described,  134 

where  it  occurs,  134 
Bubbling  rales,  154 
Buccinator  nerve,  illustrated,  485 
Bulb,  EaR  with  disease  of  the  motor 

nerves  of,  524 
Bulbar  paralysis,  absence  of  bone  re- 
flex in,  500 
of  reflex  of  pharynx  in, 
497 
cyanosis  in,  43 
EaR  with,  524 
increased  secretion  of  saliva 

in,  577,  578 
lessened  excitability  in,  with- 
out EaR  in,  525 
paralysis  of  diaphragm  in,  90 
of  recurrent  nerve  with, 
538,599 
position  of  the  soft  palate  in, 

538 
power  to  cough  lost  in,  165 
quick  pulse  with,  577 
rigid  thorax  in,  91 
salivation  in,  289 
speech  in,  548 
pulse  (bulbus  jugularis),  265 
Bulbus  jugularis,  263,  265 

murmur  at,  in  tricuspid  in- 
sufficiency, 268 
Bumm,  reference  to,  604 
Bursa  omentalis,  299 
Butyric  acid,  formation  of,  in  stomach, 

345 
Buzzing  felt  near  the  heart,  204 


G 


abbreviation  for  contraction. 
'f    Ca,  abbreviation  for  cathode,  506 
Cachectic   conditions,  chloride  of  so- 
dium in  urine  diminished  in,  434 
Cachexia,  chronic,  disturbance  of  con- 
sciousness in,  471 
defined, 35 
delirium  in,  471 
diminished  volume  of  abdomen 

in,  309 
general  atrophy  in,  491 
indican  in  urine  of  severe,  409 
leucocytosis  in,  278 
malarial,  41 
oxaluria  in,  430 


Cachexia,  poikilocytosis  in,  277 
severe,  ecchymosis  in,  51 
state  of  skin  in,  36 
temperature  in,  64 
urea  diminished  in  all  kinds  of, 
434 
Cadaveric  odor  of  breath,  285 
Caecum,   to   be   examined  in  sudden 

obstipation,  369 
Calcifications  in  pericardium,  friction 

sounds  from,  232 
Callus,  cause  of  pressure  on   nerves, 

469 
Camman,  reference  to,  140 
Cancer.     See  also  Carcinoma. 

cachexia  of  oxaluria  with,  430 

poikilocytosis  in,  277 
of  head  of  pancreas,  a  cause  of 

jaundice,  47 
of  rectum,  pain  at  stool  in,  370 
of  stomach,  alkaline  vomit  in,  366 
palpation  of,  303 
use  of  sound  in,  302 
navel  on    liver  in   carcinoma  of 

liver,  325 
paleness  in,  41 
Cancrum  oris,  description  of,  288 
Cantani,  reference  to,  430 
Cantharides,  fibrin  in  urine  in  poison- 
ing by,  439 
Capillaries,  arterial  pulse  propagated 

through,  268 
Capillary  pulse  described,  256 
Capsule,   inner,  lesion  of,  with  hemi- 
chorea,  535 
internal,  454,  461 
Caput  Medusge  defined  and  explained, 
262 
quadratum,  464 
Carbolic    acid,    color   of   urine   after 

taking,  411,  435,  451 
Carbonate  of  lime  in  urine,  431 

illustrated,  431 
Carbonic  acid,  accumulation  of,  a  cause 
of  cyanosis,  42 
diagnostic     importance    of, 

270 
eff^ect  of  poisoning  by,  upon 

color  of  blood,  270 
in  blood,  cause  of,  43 
increased    exhalation   of,  in 
fever,  60 
oxide  poisoning,  absorption  bands 
in  blood  in,  272 
Carcinoma.     See  also  Cancer, 
acetonuria  in,  448 


INDEX. 


621 


Carcinoma,  delay  in  absorption  from 
stomach  in  case  of,  355 
disturbance  of  consciousness  in, 

470 
effect  of,  on  consistence  of  liver, 

326 
epithelial,  in  larynx,  illustrated, 

696 
inherited,  20 
irregular    enlargement    of   liver 

with,  322 
nutrition  poor  in,  575 
of  gall-bladder,  326 
of  kidney,  palpation  of,  395 
of  larynx  described,  597 
of  liver,  change  in  shape  of,  325 
difficult  to  distinguish  from 

that  of  omentum,  340 
with  and  without  tenderness, 
324 
of  lung,  deadened    sound    over, 

127 
of  oesophagus,  292,  294,  296 
affecting  the  larynx,  75 
of  pancreas,  diagnosis  of,  340 
of  peritoneum,  315 
of  skull-wall,  465 
of  spleen,    unequal   enlargement 

from,  335 
of  stomach,  absence  of  free  muri- 
atic acid  in,  356 
hvpersecretion    in    cases   of, 

'357 
local     increased     resistance 

with,  302 
pain  of,  304 
of  tongue,  286 

shreds  of  tissue  in  stools  in,  377 
ventriculi,  hemorrhage  from,  362 
peptonuria  with,  439 
Carcinomatous  pleuritis,  cells  in  exu- 
dation of,  161 
ulceration  of  rectum,  hemorrhage 
from,  375 
Cardia  of  stomach,  position   of,  298, 

299 
Cardiography  of  apex-beat,  202 
Caries  of  rib,  pain  in,  101 

cause  of  pleurisy,  102 
of  vertebrae,  tenderness  with,  467 
Carotid  artery,  left,  relation  to  aorta, 
clinical  importance  of  463 
pulsation  of,  in  health,  255 
pulse  in  aneurism  of  aorta,  254 
Carotids,  internal,  supply  the  brain, 
461 


Cartilage,  sound  on  percussion,  109 
CaSC,  518,  519,  523 

determination  of  minimal,  515 
early  in  tetanus,  526 
Case-taking,  value  of,  25 
CaSTe,  518 

determination  of,  515 
early  in  tetanus,  526 
Casts,  epithelial,  forms  of,  in   urine, 
424 
in  urine,  the  infallible  signs  of 

nephritis,  420 
of  red  blood-corpuscles,  ilustrated, 

424 
renal,  kinds  of,  422 

preparation  of,  for  examina- 
tion, 422 
Catalepsy  defined,  535 

rarely     occurs    with    anatomical 
diseases,  536 
Cataract  with  diabetes  mellitus,  562 
Catarrh,  acute  nasal,  a  sign  of  various 
diseases,  74 
chronic  nasal,  cause  of  neuroses, 

575 
nasal,  73 

of  intestine,  meteorism  with,  309 
of  large  intestine,  stool  of,  373 
of  larynx,  signs  of,  593 
of  stomach,   delay  in  absorption 
*  in  case  of,  355 

hypersecretion   in    cases    of, 

357 
pain  with,  303 
Catheter,  always  to  be  used  to  draw 
urine   in  cases  of  unconscious- 
ness, 401 
cystitis  excited  by,  425 
to  be  used  to  avoid  contamination 

of  urine,  399 
use  of,  a  cause  of  cystitis,  579 
shows  residual  urine,  408 
Cathodal  closure,  result  of,  506 
Cathode  (negative  pole),  515 

at  the,  contraction  at  the  closing 

of  current,  506 
of  galvanic  current,  use  of,  in  test- 
ing sensibility  of  spinal  column, 
468 
of  the    opening  current  of   sec- 
ondary     coil      stronger     than 
anode,  504 
Caudate    nucleus,    blood-supply    of, 

462 
Causes  of  disease,  exciting,  ,21 
predisposing,  21 


622 


INDEX. 


Cavities,  bronchiectatic,  micrococci  in 
sputum  from,  189 
cylindrical,  effect  of  length  upon 

pitch  of  sound,  110 
experiment  to  illustrate,  110 
in  apex  revealed  by  loud  rales, 

152 

in  lungs,  amount  of  expectoration 

from,  168 

bronchial  breathing  over,  146 

coin-shaped  sputa  from,  169 

containing  air,  closed-tympa- 

nitic  sound  from,  110 
open    or    closed,    tympanitic 

resonance  over,  131 
plegaphonia  over,  159 
large  parietal,  noise  of  spun-top 

over,  134 
with  smooth  walls,  136 
Cavity  in  lung,  if  filled,  weaker  bron- 
chial breathing  over,  147 
increased  vocal  fremitus  with, 

158 
metamorphosing  breathing  a 

sure  sign  of,  148 
purulent  sputum  from,  169 
ringing  rales  with,  152 
Celli,  reference  to,  282 
Celsius'   thermometer,  57 
Central  convolution,  459 

anterior,  blood-supply  of,  462 
left  anterior,  centre  of  acous- 
tic recollections,  555 
posterior  and  anterior,  illus 
trated,  466 
blood-supply  of,  462 
thread   of  Curschmann's   spirals 
described,  179 
Cephalalgia,  significance  of,  482 
Cercomonas  (infusorium)  in  sputum, 

183 
Cerebellum   ataxia  in  lesions  of  the 
vermiform  process,  529 
illustrated,  466 

vermiform  process  of,  lesion  of, 
534 
vertigo  with  tumor  of,472 
vomiting  in  diseases  of,  578 
Cerebral  abscesses,  585 

affections,  ataxia  in,  529 
artery,  middle,  hemorrhages  and 
emboli  most   frequent 
in,  463 
largest  vessel  of  brain,  462 
posterior,  portion  of  brain  it 
supplies,  462 


Cerebral  blowing  sound  in   children 
with  systole  of  heart,  258 
congestion,  with  albuminuria,  441 
disease,  absence  of  cough  in,  165 

severe  hiccough  in,  540 
diseases,  clonic  spasms  in  local- 
ized, 532 
hemorrhage,  Cheyne  Stokes  respi- 
ration in,  92 
irritation,  acetonuria  with,  448 
paralysis  above  the  anterior  horn, 
characteristic  sign  of,  494 
EaR  not  present  in,  525 
in  children,  hemiathetosis  in, 

535 
increase  of  tendon  reflex  in, 
500 
symptoms,  significance  of,  587 
tumors,    Cheyue-Stokes    respira- 
tion in,  92 
Cerebro-spinal      meningitis,      herpes 

with,  50 
Cerebrum,  461 

blood-supply  of,  in  the  region  of 

fissure  of  Sylvius,  462 
disease  of,  muscular  atrophy  with, 

493 
relation  of  acostic  nerve  to,  461 
Cervical  enlargement  of  cord,  location 
of,  468 
nerves,  illustrated,  485 
vertebrae,  caries  of,  589 
Chain-coccus  in  urine,  426 
Change  of  respiratory  sound,  Fried- 
reich's, defined,  113 
of   sound,    tracheal,   Williams's, 
121,  130 
Wintrich's,  described,  111 
Charcot,  reference   to,  279,  493,  526, 

556,  557,  558,  560,  581,  582,  587 
Charcot's  crystals,  387 
Charcot-Leyden's  crystals,  179 
described,  181 
in  asthma,  388 
in  sputum,  174 
Cheek,  nerve-supply  of,  484 
Cheese-spirals,  391 
Chemical  examination  of  blood,  283 
Chemistry  of  digestion,  348 
Chest,  asymmetry  of,  82 

circumference  of,  in  relation   to 

weight  and  height,  35 
dimensions  of,  82 
form  of,  in  relation  to  disease,  81 
lagging  behind  of,  86 
pathological  form  of,  82 


INDEX. 


623 


Chest,  sides  of,  percussion  note  over, 
120 
-wall,  affections  of,  which  cause 
deadened  sound,  130 
inflammatory      diseases     of, 

weaken  apex-beat,  201 
thickening    of,    a    cause    of 
diminished     vesicular 
breathing,  145 
weakened  vocal  fremitus 
with,  158 
Cheyne-8tokes  respiration  described, 
91,  92,  93 
dyspnoea  in,  94 
increased    vesicular 

breathing  in,  144 
with  uraemia,  440 
Chiasm,    pressure    upon,    atrophy   of 

optic  nerve  from,  601 
Children,  area  of  heart-dulness  in,  205 
arrest  of  growth  of  bone  in  paral- 
ysis of,  583 
at  first  naturally  ataxic,  527 
cancrutu  oris  in,  288 
capillary  bronchitis  in,  152 
cerebral  blowing  sound  with  sys- 
tole of  heart  in,  258 
choreic  motions   in   encenhalitis 

in.  535 
color  of  stool  in,  373 
cracks  in  lips  of,  a  sign  of  heredi- 
tary syphilis,  285 
diaceturia  in  fever  of,  447 

as  an  independent  disease  in, 
447 
ease  with  which  they  vomit,  358 
edge  of  liver  distinct  in,  323 
effect  of  severe  diarrhoea  in,  upon 
amount  of  blood  in  the  body, 
270  _ 
elasticity  of  thorax  in,  effect  on 

rales,  153 
epileptiform  attacks  from  various 

causes,  533 
examination  of,  for  eruption  of 

teeth  in,  285 
expansion     of    lungs     in,    after 

whooping-cough,  136 
frequency  and  character  of  stools 

in,  368 
gallop  rhythm   a  sign  of  heart- 
failure  in,  221 
heart-sounds  in,  216 
hemiathetosis  in  cerebral   paral- 
ysis in,  535 
how  to  examine  mouth  of,  284 


Children,  kinds  of  fungus  spores  in 
stools  of,  388 
laryngitis  in,  593 
lientery  stools  in,  372 
meat-juice    stools    in   catarrh   of 

large  intestine  in,  375 
nervous  disturbances  from  intes- 
tinal parasites  in,  578 
nursing,   sour  odor  of  stool  nor- 
mal in,  371 
percussion  note  in,  120 
position  of  apex-beat  in,  198 

of  heart  in,  192 
pulse  in,  with  febrile  disease,  239 
rapid  breathing  in  fever  of,  94 
reaction  of  stool  in,  372 
relative  heart-dulness  in,  207 
retro-pharyngeal  abscess  in,  290 
round  worms  in,  380 
size  of  liver  in,  320 
sounding  oesophagus  of,  293 
thrush  in,  288 

yielding  thorax  of,  permits  pro- 
jection in  enlargement  of  liver, 
321 
Chill  described,  62 

with  rise  of  temperature,  signifi- 
cance of,  64 
Chittenden,  reference  to,  439 
Chlorate  of  potash,  color  of  blood  in 
poisoning  by,  270,  271 
poisoning  by,  causing  haema- 
to-jaundice,  47 
Chloride   of  calcium,   poisoning   by, 
methsemoglobin    in    blood   in, 
272 
of  iron  reaction,  test  for  acetone, 

414 
of  sodium,  amount   of,  in  urine 
405 
in  urine,  434 
Chlorides  usually  diminished  in  fever, 

60 
Chloroform  poisoning  causing  hsema- 
to-jaundice,  47 
odor  of  breath  in,  285 
Chlorosis,  blood-corpuscles  markedly 
pale  in,  275 
color  of  blood  in,  271 
dizziness  with,  471 
Egyptian,  41 

heart-sounds  strengthened  in,  217 
murmurs  heard  in,  229 
no  notable  diminution  of  red  cor- 
puscles   in,    in    contrast   with 
.anaemia,  276 


624 


INDEX. 


Chlorosis,  paleness  in,  due  to  loss  of 
hsemoglobin,  41 
red  blood-corpuscles  not  dimin- 
ished in,  274 
use  of  Fleischl's  hsemometer  in, 

276 
venous  humming  in,  269 
Choked  disk,  b^,  587 

absence  of,  in  bulbar  paral- 
ysis, 496 
from  intra- cranial    pressure, 

600  _  _ 
recognition  of,  601 
unilateral,  565 
Cholseraia,  47 

Cholera   Asiatica,  alkaline  vomit  in, 
366 
anuria  with,  407 
bacillus,  cultures  of,  607 

described  and  illustrated, 

389 
mode  of  preparation  of, 

389  _ 
necessity  of  pure  culture 
of,  890 
color  of  stool  in,  373 
effect    of   discharges   in,  on 
amount   of    blood  in    the 
body,  270 
examination  of,  606 
increased  peristalsis  in,  366 
indican  in  urine  of,  409 
great   quantity   of  stool    in, 

370 
mucus  in  stools  of,  374 
odor  of  stools  in,  372 
peculiar  vomit  of,  described, 

361 
saliva  diminished  in,  289 
severest  diarrhoea  with,  369 
sweat  in,  38 

watery  stools  in,  371,  374 
morbus,  mucus  in  stools  of,  374 
Cholesterine,  crystals  of,  in  sputum,  181 
Chorda  tympani,  461,  484 
Chorea  minor  described,  534 
significance  of,  535 
Choroid,  tubercle  of,  601 
Choroidal  tuberculosis,  562 
Choroiditis  syphilitica,  601 
Chronic  diseases,  development  of,  in- 
dicated by  weight  of  body, 
35 
outbreaks  of,  22 
Chyluria,  fibrin  in  urine  in,  439 
lipeemia  in,  280 


Chyluria,  Hpuria  in,  447 

produced  by  filaria  sanguinis,  425 
rare,  412 
Ciliated  epithelium,  transfer  of  mucus 

bv,  167 
Circle  of  Willis,  461 
Circulation,    disturbance  of,   causing 
paleness,  40 
through  lungs,  44 
Circulatory    aouaratus,    examination 
of,  i91 
disturbances  of,  576 
Circulus  vitiosus,  in  stomach,  345 
Circumference  of  thorax  increased  in 
inspiration,  163 
where  measured,  162 
Circumpolarization     for    determining 

presence  of  sugar,  447 
Cirrhosis  of  liver,  ascites  with,  314 
bloody  vomit  in,  361,  362 
consistence  of  liver  in,  326 
diminished  area   of  dulness 

with,  331 
enlargement  of  spleen  with, 

335 
made  out  after  tapping  abdo- 
men, 318 
surface  of,  325 
urine  of,  dark,  408 
venous   engorgement   caused  by, 
262 
Clarke,  columns  of,  459 
Clavicular  depressions  deepened,  87 
Clavus  hystericus,  482 
Clear  sound  defined,  106,  109 

from  closed  air-cavity,  110 
Clinical   study,  value  of  case-taking 

in,  25 
Clonic  spasms,  530 

when  occur,  532 
Closed  tj'mpanitic  sound  defined,  110 
heard  over  stomach.  111 
Clothing,  eiFect  of,  on  disease,  21 
CO2  in  blood,  effect  of,  on  breathing,  93 
Coagulation   of    blood    slower  when 

nutrition  is  disturbed,  283 
Coal-dust  in  epithelial  ceils  in  sputum, 
177 
-soot  in  sputum,  171,  176 
Cocaine,  effect  of,  on  pupil,  567 
Cocci  in  urine,  425 
Cod-liver  oil,  lipuriawhen  taking,  447 
CofFee-grounds-stool,  in  gastric  hem- 
orrhage, 375 
-vomit  explained,  363 
Cohnheim,  reference  to,  53,  54,  407 


INDEX. 


625 


Cohnheim's      hypothesis      regarding 

dropsy  of  kidney  disease,  440 
Cold  baths,  value  of  pulse  in  showing 
result  of.  253 
catching,  disposition  to  headache 
with,  483 
Colic,  abdominal,  from  passage  of  gall- 
stones, 37() 
Collapse,  cold  sweat  of,  38 
described,  63 
from  hemorrhage  in  casesof  ulcer 

of  stomach,  362 
shown  by  fall  of  temperature,  65 
weakness  of  apex-beat  in,  201 
Colon,  boundary  between,  and  small 
intestine   312 
distention  of,  for  purposes  of  diag- 
nosis  311,  312 
fecal  masses  in,  increases  the  area 
of  dulness  near  the  spleen,  338 
position  of,  illustrated,  298 
relation  of,  to  spleen,  336 
transverse,  scybala  in,  303 
tumors  of  transverse  and  descend- 
ing, confounded  with  those  of 
spleen  and  kidney,  311 
Color  of  expectoration,  168 
of  skin,  38 
of  tongue,  287 
of  urine,  401 

-sense,  testing  the,  568,  571 
Columns  of  Clarke,  459 
of  Goll,  459 
of  Tiirck,  455 
Coma  defined,  470 
diabetic,  579 

acetone  odor  of  urine  in,  414 
;S-oxybutyric   acid   in   urine 

of,  449 
diaceturia  in,  447 
odor  of  breath  in,  285 
difficulties  of  diagnosis  in,  471 
from  diaceturia,  448 
post-epileptic,  533 
ursemic,  440 

with  diabetes  mellitus,  579 

Comma  bacillus,  Koch's,  distinguished 

fromFinkler-Prior'sbacillus,390,607 

Communicating  artery,  posterior,  461 

Comparative    percussion,    118,     121, 

125 
Compensation  of  heart  disease,  pulse 
in  arrested,  240 
of  valvular  deficiency,  195 
Compensatory    hypertrophy    of    one 
division  of  heart,  219 


Complementary  pleural  sinus,  80 
exudation  into,  306 
space,  192 
Complication    of   disease    shown   by 

temperature,  &^ 
Complications,  value  of  pulse  in,  show- 
ing beginning  of,  253 
Concealment  of  disease,  19 
Concentrated  urine,  appearance  of,  402 
Conception  of  space,  how  tested,  481 
Concretions  in  urine,  433 
Concussion    of   cranium,  disturbance 

of  consciousness  in,  471 
Conduction,  resistance  to,  512 
Conductive  resistance,  514 

variations  of,  due  to  thickness 
of  skin,  513 
Confinement  to  bed,  ataxia  after,  529 
Confluent  sputa,  169 
Congenital  drawing  in  of  thorax,  89 
Conjugate  deviation,  566 
of  the  eye,  563 
Conjunctiva,  color  of,  39,  note. 

nerve  supply  of,  484 
Consciousness,  change  of,  in  Cheyne- 
Stokes's  breathing,  93 
diseases  in  which  disturbances  of 

occur,  470 
disturbances  of,  terms  used  for, 

470 
loss  of,  40 

sign  of,  489 
mydriasis  with  marked   disturb- 
ance of,  566 
never   an  entire  loss  of,  in  hys- 
terical convulsions,  533 
obtunded,  phenomena  of,  471 
when  there  is  loss  of,  heart  and 
vessels  to  be  examined,  577 
Consensual  reaction  of  pupils,  567 
Consistence  of  expectoration,  168 
Consonance  increases  vocal  fremitus, 

158 
Consonant  rales,  152 
Constipation,  368 

alternating  with  diarrhoea,  369 
and     severe     obstruction    to    be 

sharply  distinguished,  369 
habitual,    in   diseases    of   spinal 
cord,  578 
Constrained  positions  and  motions  de- 
fined, 534 
Constricted  liver  from   tight    lacing, 

323 
Constriction,  feeling  of,  about  thorax, 
482 


40 


626 


INDEX. 


Contagion  distinguislied  from   infec- 
tion, 22 
Continued  fever,  range  of  temperature 

of,  62 
Continuous  fevers,  red  skin  in,  41 
Contracted  kidney,  casts  in  urine  of, 
422 
diminished  urine  vpith,  407 
,    polyuria  with,  406 
retinitis  in,  601 
pupil,  566 
Contraction,  character  of,  518 
laws  of,  505 

■  normal,  with  galvanic  stimu- 
lation, 506 
minimal,  505,  515,  516 
quality  of,  sometimes  important, 

515,  516 
tetanic,  505 
Contractions,  idio-muscular,  defined, 
526  _ 
lightning-like,  507 
of  fibrilte,  630 
paradoxical,  defined,  527 
quality  of,  depends  upon  relation 

of  the  nerve  to  the  skin,  504 
slowness  of,  in  partial  EaE,  523 
Contracture  due  to   over-excitability 
of  nerves  and  muscles,  526 
of  muscles  in  paralysis,  495 
Contractures  wanting,  493 
Conus  aortse,  193 

arteriosus,  sound  caused  by  filling 

of,  213 
terminalis  of  cord,  location  of  468 
Convalescence  indicated  by  weight  of 
body,  35 
perspiration  in  commencement  of, 

38 
pulse  in,  235 

temporary  imbecility  in.  472 
Convolution,  anterior  central,  454 
left  anterior    central,    centre    for 
acoustic  recollection,  555 
second  frontal,  motor  centre 

for  writing,  555 
third  frontal,  motor  speech- 
centre,  555 
posterior  central,  454 
Convolutions  of   brain,   anterior   and 
posterior      central,     blood 
supply  of,  462 
posterior    and  'anterior  cen- 
tralj  illustrated,  466 
Convulsions.     Also  see  Spasms 
clonic  spasms  in,  532 


Convulsions,  difference  between  hys- 
terical and  epileptic,  533 
due  to  eruption  of  teeth,  286 
epileptic  and  hysterical,  opistho- 
tonus with,  468 
hysterical,    texanic,    perspiration 

in,  37 
in  children,  diaceturia  thought  to 

be  the  cause  of,  448 
l^roduce  cyanosis,  42 
sign  of  nervous  disease,  22 
simulation  of,  19 
with  ursemia,  440 
Cooing  in  intestine,  value  of,  312 
Coordinated    motions  in  hystero-epi- 
lepsy,  533 
spasms,  634 
Coordination  defined  and  explained, 
527 
disturbances  of  in  the  larynx,  597 
how  acquired,  527 
of  muscles,  488 
temporary  loss  of,  529 
Copaiva,  odor  of  urine  after  taking, 

414 
Copper,  condition  of  teei^h  in  poison- 
ing by,  286 
Copying,  power  of,  550 
Cord,  compression  of  spinal,  467 
spinal,  effect  of  lesion  of,  457 
Corona  radiata,  454 

effect  of  lesion  of,  457 
Corpora  quadrigemina,  ataxia  in  le- 
sions of,  529 
blood  supply  of,  462 
Corpulence,  35 

increases  area  of  dulness  near  the 
spleen,  338 
Corpus  quadrigeminum,  lesion  of  pos- 
terior, 566 
Corpuscles,  mucous,  in  sputum,  175 
Cortex    of    brain,    clonic   spasms    in 
local  affections  of,  532 
effect  of  lesion  of,  457 
partial   epilepsy  a  sure  sign 

of  disease  of,  533 
spasms  from  irritation  of  the, 
530 
Cortical  centres,  lesion  of,  results  of, 
456 
where  their  trophic  influence 
ceases,  466 
Cortico-muscular  tract,  452,  456 
Corvisart,  reference  to,  104 
Costal  breathing,  absence  of,  how  met, 
91 


INDEX. 


627 


Costal  breathing   absent  in   emphy- 
sema, 84 
defined,  83 
how  changed,  90 
in  place  of  diaphragmatic,  95 
often  wanting  in  women,  85 
Costo  -  abdominal      breathing,     how 

changed,  90 
Cough,    diseases    and    conditions    in 
which  it  is  absent,  165 
dry,  defined,  166 
frequency  of,  and  time  of  day  of, 

significance  of,  165 
moist,  described;  166 
nervous,  576 
parts  of  mucous  membrane  from 

which  it  arises,  165 
phenomena  of,  explained,  164 
power  to,  when  lost,  165 
spontaneous,  or  reflex,  165 
suppression  of,  from  pain,  165 
tones  of,  described,  166 
vomiting  from  violent,  358 
Coughing,  effect   on   venous   circula- 
tion, 263 
produced  by  attempts  at  swallow- 
ing in  paralysis  of  pharyngeal 
muscles,  538 
removes  rales,  149 
Coupland  quoted,  26 
Covering  of  body,  effect  on  vocal  fre- 
mitus, 157 
"Cracked-pot"  sound,  described,  134 

where  heard,  134,  135 
Cranial  fossa,  anterior,  middle,  poste- 
rior effect  of  lesion  of,  457 
nerves,  nuclei  of,  illustrated,  455 
points  of  exit  from  skull,  illus- 
trated, 458 
walls,  disease  of,  465 
Cranium,  diseases  of,  headache  with, 
482 
examination  of,  465 
local  diseases  of,  hearing  in,  572 
rhachitic  thickening  of,  464 
sensibility  of,  to  pressure,  466 
size  of,  at  different  ages,  464 
Creasote,  color  of  urine  after  taking, 

411 
Cremaster  reflex,  defined,  495,  495 
Crepitant  rales  defined,  154 

in  capillary  bronchitis.  152 
Crepitation,  non-uniform,  154 
Crepitations   in   mediastinal    emphy- 
sema, 233 
Cretinism  defined,  472 


Cretins,  skeleton  of,  33 
Crisis  defined,  67 

signs  of,  63 
Critical  sweat  in  various  diseases,  37 
Crossed   paralysis  (oculomotorius)  of 
one   side   and  extremity  of  other, 
566 
Cross-section  of  chest,  163 
Croup,  75,  98 

casts  in  sputum  of,  172 
cause  of  cyanosis,  43 
dyspnoea  in,  93,  94 
severe  cough  of  a  cause  of  emphy- 
sema of  skin,  56 
tone  of  cough  in,  166 
Croupous   pneumonia,  one-sided   ex- 
pansion of  chest  in,  86 
Crura  cerebelli,  ataxia  in  lesions  of, 

529 
Crural   arterial    and   venous    sounds 
combined,  269 
artery,  double  murmurs  in,  259 
nerve,  illustrated,  487 
vein,    double    sound    over,    how 
distinguished    from   that    over 
crural  artery,  268 
Crus  cerebri,  454,  457 
injury  of,  457 
lesion    of,   crossed   paralysis 

with,  566 
median,  lesion  of,  534 
Crutch  paralysis,  488 
Crystals,  fat,  distinguished  from  elas- 
tic threads  in  sputum,  177 
in  sputum,  174 
in  blood  in  leuksemia,  279 
in  feces,  387 

in  sputum,  kinds  of,  180 
of  cholesterine  in  sputum,  181 
of    fatty    acids    in    sputum    de- 
scribed, 181 
Cubebs,  odor  of  urine  after  taking, 

414 
Current-changer,  506 
use  of,  505 
density   of,  in   nerves   and  skin, 

603 
electric,  cannot  be  concentrated 

on  nerve,  503 
reasons  why,  504 
strength    of,   as  affected   by  the 
angle  of  entrance  of,  604 
increases,    while    electrodes 

are  on  the  body,  503 
of  total,  612 
of  total,  must  be  known,  513 


628 


INDEX. 


Curschmann,  reference  to,  179,  180 
Curschmann's  spirals  in  sputum,  178 
Curvature,  greater,  of  stomach,  ana- 
tomical   relations    of, 
299 
boundary  of,  305 
in  distention,  301 
position  of,  298 
when  dulness  over,  306 
lesser,    of   stomach,     anatomical 
position    of,  298 
relations  of,  299 
Curve,  Damoiseau's,  129 
Cutaneous  nerves  of  lower  extremity 
illustrated,  487 
of  shoulder,  arm,  and  hand, 
distribution  of,  illustrated, 
486 
veins,  enlargement  of,  262 
Cyanosis,  a  result  of  general  venous 
engorgement,  261 
causes  of,  43 
described,  42 

from  interference  with  respiration 
•  during  an  attack  of  epilepsy,  533 
from  poisons.   See  Examination  of 

Blood, 
from  severe  coughing,  166 
in  paralysis,  577 
in  tetanus  and  epilepsy,  540 
of  newborn,  42 
sometimes  absent  in  tuberculosis 

pulmonum,  44 
with  dyspnoea,  99 
Cyclic  albuminuria,  435,  437 
Cylindrical  cavities,  effect  of  length 
of,  upon  pitch  of  sound,  110 
experiment  to  illustrate,  110 
Cylindroids  in  urine  not  to  be  con- 
founded with  casts,  424 
Cystic  hemorrhages,  very  free,  charac- 
teristics of,  418 
Cystin  in  urine,  significance  of,  432 

-calculi,  432,  433 
Cystitis,  alkaline  urine  with,  413 
caused  by  cystin,  432 

by  ptomaines,  432 
from  use  of  catheter,  579 
hsematuria  from,  417 
hydrothionic  urine  with,  414 
micrococci  and  bacilli  in  urine  of, 

425 
mucus  in  urine  of,  416 
odor  of  urine  in,  415 
sediment  in  urine  in,  419 
signs  of,  400 


Cystitis,  turbid  urine  with,  412 
with  a  nervous  disease,  575 
Cystometer,  Woillez's,  163 
Cystopyelitis,  398 


DAMOISEAU'S  curve,  129 
Dax,  M.,  reference  to,  552 
Deadened  resonance,  125 

sound  associated  with  feeling  of 
strong  resistance,  116 
defined,  109 
from  thick  skeletal  covering, 

114 
relatively,  where  occurs,  114 
where  heard,  109,  113 
Deadening,  relative  heart  and  liver,112 
Deadness  applied  to  sound,  106 

area  of,  increased  with  extent  of 

exudation,  128 
of  sound  over  pleural  thickening, 

148 
relative,  of  sound  defined,  107 
Deafness,  absolute  and  relative,  108 

nervous,  572 
Decomposition  of  intestinal  contents, 
vegetable  parasites  in  feces  in,  388 
Decubitus  acutus  defined,  582 
described,  582 

disturbance  of  nutrition  with, 
575 
Deep  breathing,   employment  of,  in 
examining  the  abdomen,  323 
lung  sound,  108 
sensibility,  473 

part   of,  in   recognizing  the 

form  of  bodies,  481 
section  on,  479 
Defecation,    assisted    by    abdominal 

pressure,  540 
Defervescence,  stage  of,  65 
Deformity  of  chest,  81 
Degeneration,  character  of,  as  deter- 
mined by  location  of  lesion,  456 
funnel-breast  a  sign  of,  89 
of    hypertrophied     heart,    weak 

apex  beat  in,  201 
of  nerves  and  muscles,  520 
primary  and  secondary,  increase 

of  tendon  reflex  in,  500 
reaction  of,  complete  and  partial, 
519 
Degenerative  atrophic  paralysis,  492, 
493,  518 
atrophy.  490,  493 

difficulty  of  diagnosis  in,  491 


INDEX. 


629 


Degenerative  atrophy,  when  wanting, 
491 
paralysis,  495 
Deglutition -pneumonia,  600 
Dehio,  reference  to,  143 
Delayed  sensibility,  478 
Delirium,  defined,  and  the  diseases  in 
which  it  occurs,  471 
in  gross  hysteria,  534 
-muttering  in  typhoid  fever,  471 
tremens    in    alcoholic    poisoning 

described,  471 
witli  uraemia,  440 
Dementia  paralytica,  atrophy  of  optic 
nerve  in,  601 
character  of  the  writing  of, 
561 
senile,  mixed  aphasia  and  amne- 
sia in,  555 
senilis,  472 
Deneke,  reference  to,  391 
Dentition,  cause  of  epileptiform  at- 
tacks in  children,  533 
disturbances  due  to,  286 
Deposits,  pyaemic,  in  lungs,  friction- 
sounds  with,  156 
Depression,  clavicular,  81,  82,  84 
■  Morenheim's,  defined,  76 
states  of,  acetonuria  in,  448 
Desaga,  spectroscope  devised  by,  272 
Descendants  divided  by  heredity,  20 
Desquamation  of  renal  epithelium  in 

acute  nephritis,  424 
Detritus  in  stools,  887 
Development,  errors  of,  funnel-breast 

a  sign  of,  89 
Deviation,  conjugate,  534 

primary,  secondary,  563 
Diabetes,  acetone  odor  of  breath  in, 
285 
alkalescence  of  blood  in,  dimin- 
ished in,  283 
diminished  sweat  in,  38 
disturbance  of  consciousness  in, 

470 
dyspnoea  in,  576 
gangrene  in,  577 
insipidus,  579 

inosite  in  urine  in,  447 
lipaemia  in,  280 
mal  perforant  in,  582 
mellitus  and    insipidus,  polyuria 
with,  406 
apple  odor  of  urine  in,  414 
caries  of  teeth  in,  285 
cataract  with,  562 


Diabetes  mellitus,  character  of  urine 
in,  443 

contradictory     character    of 
urin'^  in,  diagnostic  value 
of,  409 
diaceturia  in,  447 
effect  of,  on  weight  of  body,  36 
levulose  in,  447 
lipuria  in,  447 
oxalate  of  lime  in  urine  of, 

430 
percentage  of  sugar  in  urine 

of,  443 
polyuria     of    secondary     to 

polydipsia,  407 
specific  gravity  of  urine  in, 

412,  413 
thirst  in,  23 

various  nervous  disturbances 
with,  579 
neuralgia  in,  483 
ocular  changes  in,  602 
oxalate  of  lime  in  sputum  of,  182 
saliva  diminished  in,  289 
thrush  with,  288 
Diabetic  coma,  acetone  odor  of  urine 
in,  414 
/3-oxybuteric   acid   in    urine 

of,  449 
odor  of  breath  of,  285 
sometimes   increased  vesicu- 
lar breathing  with,  144 
Stadelmann's       observations 
on.  449 
Diaceturia,  an  independent  disease  in 
children,  447 
comparison  of  color  of  urine,  with 

test  for  salicylic  acid,  450 
in  adults,  when  occurs,  448 
in  children  the  cause  of  convul- 
sions, 448 
test  for,  448 
when  occurs,  447 
Diagnosis  defined,  17 
Diameter  of  thorax,  how  measured, 

162 
Diaphragm,  action  of,  in  stenosis  of 
upper  air-passage,  98 
interfered  with,  90 
tested  by  palpation,  103 
adjacent  to   fundus   of  stomach, 

299 
depressed  by  exudation,  128 

in  exudative  pleuritis,  330 
depression  of,  from  emphysema, 
199 


630 


INDEX. 


Diaphragm,  effect  of  paralysis  of,  540 
of  position  of,  on  relative  liver 

dulness,  332 
of  pressure  upon,  may  inter- 
fere with  action  of  heart,  40 
elevation  of,  causes  dislocation  of 

heart,  200 
fixation  of,  in  hysteria,  576 
high  position  of,  87,  130 

due  to  abdominal  disten- 
tion, 317 
diminishes  area  of  spleen 

dulness,  339 
from  paralysis,  in  peri- 
tonitis, 317 
increased  parietal  area  of 
heart  with,  211 
liver  moves  with,  320 

in  inspiration,  322 
low   position   of  renders   spleen 

accessible,  335 
paralysis  of,  inspiratory  dyspnoea 

from,  99 
position  of,  80 

aids  diagnosis  between  pleu- 
ral exudation   and  thick- 
ened pleura,  130 
changed     with     diminished 

volume  of  lungs,  137 
in  children,  192 
of  the  heart  changed  by  de- 
pression of  204 
pressed  upon  by  meteorism,  309 

upward  by  enlarged  liver,  322 
pressure  upon,  a  cause  of  paleness, 

40 
pushed  up  by  subphrenic  abscess, 

322 
rapid  breathing  in  diseases  of,  94 
relation  of  spleen  to,  332 
to  liver,  320 
with  other  organs,  312 
spasm  of,  94,  540 
trichinosis  of,  pain  in,  a  cause  of 

cyanosis,  44 
upward  displacement  of  liver  in 
paralysis  of,  323 
pressure  of,  cyanosis  from,  43 
vesicular  breathing  increased  on 
account  of  high  position  of,  145 
Diaphragmatic  breathing,  83 
in  place  of  costal,  95 
friction  sounds,  233 
peritonitis,  simulates  pleuritis,161 
pleurisy,   tympanitic     sound     in 
lung  over,  130 


Diarrhoea,  alternating  with  constipa- 
tion, 369 
brick-dust  sediment  in  urine  of, 

430 
causes  diminished  sweat,  38 
color  of  stool  in,  373 
defined, 368 

due  to  eruption  of  teeth,  286 
effect  of  severe,  on  the  amount  of 

blood  in  the  body,  270 
foul-smelling  stool  in  severe,  372 
infusoria  found  in  stools  of,  383 
less  amount  of  urine  in,  407 
quantity  of  stool  increased  in,  37C 
saliva  diminished  in,  289 
watery  stools  in,  374 
Diastole  of  heart,  sound  of,  what  due 
to     and     where     best 
heard,  213,  214 
sound  with,  212 
venous  humming  louder  dur- 
ing, than  in  systole,  269 
of  ventricle,  movement  of  blood 
in,  193 
Diastolic  collapse  of  cervical  veins, 
267 
murmur  at  aorta,  251 
murmurs,  222,  225 

how  distinguished  from  sys- 
tolic, 226 
sound  over  large  arteries  in  health, 
257 
Diazo-benzol-sulphuric   acid   test  for 

sugar,  445 
Dicrotic  pulse,  tracings  of,  248 
Dictation,  writing  from,  550 
Diet,  coating  of  tongue  from  articles 
of  287 
effect  on  disease,  21 
Differential    diagnosis  between    peri- 

and  endocardial  murmurs,  232 
Differentiating  electrode,  501 
Difficult  breating,  93 
Digestion,  aided  by  mechanical  action 
of  stomach,  347 
amylolytic  period  of,  342 
bacteria  in  feces  in  anomalies  of, 

388 
character  of  stools  in  disturbance 

of,  372 
chemical  action  during,  347 
duration  of  347 
examination  of  process  of,  342 
intestinal,  shown  by  stools,  367 
mode  of  procedure  in  examining, 
350 


INDEX. 


631 


Digestion,  normal,  test  of,  348 

particles  of  food  found  in  stools 

in  disturbed,  386 
period  of,  prolonged,  356 

shortened,  356 
prolonged  in  dilated  stomach,  346 
study  of  process  of,  341 
washing  out  the  stomach  in  dis- 
turbance of,  357 
Digestive  apparatus,  change  in  weight 
in  diseases  of,  35* 
examination  of,  284 
section   on    disturbances    of, 
577 
Dilatation  of  heart,  a  cause  of  insuf- 
ficiency, 194 
area  of  dulness  enlarged  in, 

208,  209 
cause  of  projection  of  region 

of  heart,  202 
eccentric,  195 
in  angemia,  229 
simple,  196 
of  stomach,  345,  348 

absence  of  free  muriatic  acid 

in,  356 
infrequency  of  the  attacks  of 

vomiting  in,  359 
with     fermentation,     recog- 
nized  by  seething  sound, 
308 
Diphtheria,  acute  nasal  catarrh  in,  74 
appearance  of  tonsils  in,  290 
death  after  examination  of  throat, 

284 
examination  of  mouth  in  cases  of, 

284 
gallop   rhythm  a  sign   of  heart- 
failure  in  221 
glands  of  neck  enlarged  in,  291 
glycosuria  in,  443 
may  cause  cyanosis,  43 
microscope  an  aid  in  diagnosing, 

from  benign  necrosis,  291 
paleness  from,  40 
paralvsis  of  tensor  of  vocal  cords 

from,  600 
sequelse  of,  22 
sometimes  uu  contraction  of  pupil 

after,  568 
tone  of  cough  in,  166 
Diphtheritic  paralysis,  position  of  the 

soft  palate  in,  538 
Diplococci  in  purulent  pleural    exu- 
dation, 161 
Diplococcus  in  urine,  399 


Diplopia  defined   and   when   occurs, 
472 
mode  of  determining,  564 
result  of  strabismus,  563 
significance  of,  564 
Direct  percussion  defined,  104 
Discharges,  in  voluntary,  during  attack 

of  epilepsy,  533,  534 
Disease,  first  appearance  of,  23 

location  of,  sometimes  indicated 

by  headache,  482 
simulation  of,  19 
Diseases,  acute,  power   of  resistance 
to,  33 
sometimes  no  contraction  of 
pupil  after,  568 
ataxia  after  acute,  529 
concealed,  19 
course  of,  23 
directly  inherited,  20 
exciting  causes  of,  21 
internal,  and  form  of  thorax,  81 
names  of,  misused,  19 
predisposing  causes  of  21 
tracing  of  pulse  in  wasting,  248 
wasting,  hsemic  murmurs  in,  229 
Displacement  of  apex-beat,  199 
Disposition  to  disease  inherited,  20 
of  lungs,  81 
emphysema,  with  full  chest,  34 
tuberculosis,  34 
Distention  of  stomach,  300,  301 

artificial,  methods  of,  301,  302 
Frerich's  formula  for,  301 
Ziemssen's  formula  for,  302 
Distoma  haematobium,  cause  of  hsema- 
turia,  283,  425 
eggs  of,  in  urine,  425 
illustration  of,  282 
hepaticum    and   distoma  lanceo- 
latum  described,  383 
illustrated,  384 
pulmonunj,  eggs  of,  in  sputum, 183 
in  sputum,  174 
Disturbances  of  speech,  548 
Disturbed  sensibility,  local  manifesta- 
tions of  478 
Dizziness,  also  see  Vertigo,  from  the 
eye,  563 

combined  with  tinnitus  aurium,  575 
sisrnificance  of,  471 
Dock,  reference  to,  282,  391 
Dolichocephalus,  465 
Dorsal  clonus,  499 

position  for  inspection  and  palpa- 
tion of  heart,  197 


632 


INDEX, 


Double  murmur  from  pressure,  259 
vision,  mode  of  determining,  564 
result  of  strabismus,  563 
significance  of,  564 
Drawing-in,  circular,  of  chest,  88 
inspiratory,  97,  98 
of  abdomen,  causes  of,  309 
of  one  side,  86 
Drinks,    certain    ones    which    cause 

polyuria,  406 
Dropsy,  anidrosis  with,  38 

of  kidney  disease,  cause  of,  440 
orthopncea  with,  33 
three  causes  of,  53 
urea  diminished  in  cachexia  with, 
434 
Drunkards,  lipsemia  in,  280 
Dry  cough  defined,  166 

rales  explained,  149 
Duboisin,  effect  of,  on  pupil,  567 
Dubois's  induction  coil,  476 
Duchenne,  reference  to,  508 
Ductus  choledochus,  46 

compression  of,  340 
Wirtungianus,  387 
Dull,  as  a  term  for  sound,  avoided,  108 

sounds,  107 
Dura  mater,  disease  of,  465 
Duration  of  digestion,  347 

of  lung  sound,  108 
Duroziez's  double  murmur,  259 
Dust,  inhalation    of,    cause  of  bron- 
chitis, 21 
of  pneumonia,  21 
Dwarf,  skeleton  of,  33 
Dynamic  sense,  479 
defined,  480 
Dynamometer,  uselessness  of,  545 
Dysarthria  defined,  548 
Dysentery,  amoeba  coli  in  stools  of,  391 
blood  in  stools  of,  373 
catarrhal,  mucous  stool  in,  374 
color  of  stool  in,  373 
consistence  and  form  of  stool  in, 

371 
feces  of,  contains  Charcot's  crys- 
tals, 388 
meat-juice  stools  in,  375 
odor  of  stools  in,  372 
pain  and  straining  at  stool  in,  370 

in  left  iliac  fossa  with,  308 
shreds  of  mucous  membrane  in 

stool  in,  377 
watery  stools  in,  374 
Dyspepsia,  acute,  paleness  in,  40 
coated  tongue  of,  287 


Dyspepsia  due  to  diseased  teeth,  286 
following  healed  ulcer  of  stomach, 

vomiting  with,  361 
foul  odor  of  breath  in,  285 
gastric,  headache  with,  483 
intestinal,  fungus  spores  in  stools, 

388 
nervous,  578 

has  marked  subjective  symp- 
toms but  no  physical  signs, 
308 
subacidity  of  stomach  in,  356 
watery  vomit  of,  361 
stools  in,  372 

superacidity  of  stomach  with,  357 
symptoms  of,  with  displacement 

of  right  kidney,  396 
time  when  vomiting  occurs  in,  359 
Dyspnoea,  32,  74 

active  expiration  of,  97 

caused  by  emphysema  of  skin,  57 

color  of  blood  in,  270 

described,  93 

expiratory  relation  to  emphysema, 

85 
from  drawing  up  of  diaphragm,  86 
from  uraemia,  440 
in  Cheyne- Stokes  breathing,  94 
in  connection  with  nervous  dis- 
eases, 576 
in  diseases  of  the  lungs,  95 
in  emphysema,  84 
in  heart  disease,  96 
in  paralysis  of  the  diaphragm,  540 
inspiratory,  74,  598 

from  paralysis  of  the  laryn- 
geal muscles,  538 
mixed,  when  exists,  100 
of  fever,  94 
sometimes     increased     vesicular 

breathing  with,  144 
usually  accompanied  by  perspira- 
tion, 37 
Dystrophia  musculorum,  493,  494,  525 


EAR,  affections  of,  in  diseases  of  the 
nervous  system,  672 

catarrh  of  middle,  a  sign  of  con- 
genital syphilis,  286 

importance  of  determining  dis- 
ease of,  572 

subjective  sensibility  of  hearing 
in  diseases  of  572 

suppuration  of,  cause  of  menin- 
gitis and  abscess  of  brain,  467 


INDEX. 


633 


Ear,  vertigo  in  diseases  of,  472 
EaR  (reaction  of  degeneration),  518 
diseases  which  are  excluded  when 

it  is  present,  525 
in  myopathic  muscular  atrophy, 

524 
partial,  522,  525 
relation  of,  to  mechanical  EaR, 

524 
significance  of  its  absence,  525 
varieties  of,  523 
when  wanting,  525 
with  reference  to  motion,  521 
Ebstein  quoted,  89 

reference  to;  205,  208,  447 
Ecchymoses,  51 

Echinococcus    bladders    in     sputum, 
174,  182 
change  in  shape  of  liver  from,  325 
in  urine,  424 
irregular    enlargement    of    liver 

with,  322 
membranous  rags  of,  in  vomit,  364 
of  kidney,  palpation  of,  395 
of  liver  a  cause  of  jaundice,  47 
depression  of  liver  from,  330 
no  tenderness  with,  324 
of  omentum  is  rare,  340 
prominences  on  liver  from,  326 
unequal    enlargement   of   spleen 
from,  335 
Ecker,  reference  to,  452,  466 
Eclampsia  gravidarum,  633 
Ectasia  of  stomach,  345 
Edelmann,  reference  to,  518 
Edelmann's   horizontal  galvanometer, 

503 
Edinger,  reference  to,  453,  455,  458 
Effusion  in  abdominal  cavity,  313 

into  cavities    a  result  of  general 

venous  engorgement,  261 
into  pleural  cavity,  serous,  puru- 
lent,    ichorous,      complicating 
pneumothorax,     diagnosis    of, 
129 
percussion  of,  in  abdominal  cavity, 
value  and  method  of,  316 
Effusions  into  pleural  sacs,  80 

large,  in  abdomen,  effect  of,  317 
Egyptian  chlorosis,  382 
Ehrlich,  reference  to,  185,  279 
Eichhorst,  reference  to,  154,  164,  208, 

247,  248,  249,  302,  424 
Elastic  fibres  a  sediment  in  sputum, 
186 
threads  described,  177 


Elastic    threads,    how    distinguished 
from    leptothrix    buccalis, 
184 
how  to  obtain,  for  examina- 
tion, 178 
importance  of,  in  sputum,  177 
Electric  sensibility,  476 
Electrical  condition,  diagnostic  value 
of,  524 
examination,   details   of  method 
of,  507 
methods  of,  505 
of  nerves  and  muscles,  501 
what  it  consists  of,  505 
irritation  of  arm,  509,  510 

points  of,  upon  the  head  and 
neck,  illustrated,  503 
reaction,  mixed,  defined,  523 

what  to  observe  in  determin- 
ing, 516 
sensibility  unchanged  in  atrophy 
of  inactivity,  490 
Electro-diagnosis,     reading    the    gal- 
vanometer in,  515 
-motor  points,  469 
Electrode  always  to  be  applied  with 
the  same  pressure,  507 
Erb's  fine,  for  faradic  current,  502, 

512 
examining  and  indifferent,  512 
for    testing    sensibility   of   skin 

illustrated,  476 
indifferent,  523 

and  differentiating,  501 
where  placed  and  size  of,  502 
place  of,  in  galvanic  examination, 

515 
relation  of  size  of,  to  intensity  of 
current,  502 
Electrotonus,  505 
Elements,  galvanic,  number  of,  514, 

515 
Emaciat'on  cause  of  narrow  chest,  85 
how  detected,  35 

produced   by  disease  of  internal 
organs,  36 
Emboli,  effect  of,  on  pulse,  245 

region   of  brain  where  most  fre- 
quent, 463 
result  of  atheroma  of  vessels,  576 
from  thrombi  in  weak  heart, 
576 
Embolism,  local,  low  temperature  in, 

71 
Embolus  of  the  central  artery  of  the 
retina,  562 


634 


INDEX. 


Emesis,   induction   of,  when   contra- 
indicated,  342 
intentional,  for  diagnosis,  305 
Emotions  causes  of  disease,  21 
Emphysema,  80,  82 

a  cause   of  hypertrophy  of  right 

ventricle,  196 
action  of  muscles  of  neck  in,  538 
and  form  of  thorax,  81. 
band  box  note  with,  135 
case  of  pernicious  anaemia  com- 
plicated by,  230 
cause  of  emphysema  of  skin,  56 
of  expiratory  dyspnoea,  99 
of  hypertrophy  of  right  ven- 
tricle, 210 
causes  diminished  parietal  area  of 

heart,  197 
clavicular  depression  in,  84 
cyanosis  in,  43 

diaphragmatic  breathing  in,  91 
diminished  amount  of  urine  with, 
407 
expiratory  pressure  in,  164 
disposition  to,  with  full  chest,  34 
distinguished  from  oedema,  55 
disturbs   circulation  through  the 

lungs,  44 
downward  displacement  of  liver 

with,  322 
dyspnoea  in,  95 

effect  of,  on  relative  liver-dulness, 
332 
on  upper  boundary  of  liver, 
330 
effects  of,  upon  venous  circulation, 

263 
enlargement  of  liver  with,  322 
expiratory  bulging  in,  98 
extension  of  boundaries  of  lungs 

in,  136 
"  gallop    rhythm "  of   heart    in, 

221 
heart-dulness  diminished  in,  210 
inspiratory  dyspnoea  with,  100 
local  expansion  of  chest  in,  86 
mediastinal,  57,  210,  233 
muscular  aid  in,  84 
non-ringing  rales  with,  153 
non-tympanitic  sound  with,  112 
of  lungs,  204 

a  cause  of  displacement  of 

heart.  199 
conceals  apex-beat,  201 

the  action  of  pulmonary 
valve,  203 


Emphysema  of  lungs  diminishes  area 
of  spleen-dulness,  339 
of  skin,  55 

in  connection  with   diseases 

of  oesophagus,  296 
weakens  apex-beat,  201 
peptonuria  with,  439 
prolonged  expiration  in,  145 
rales  with,  150 

sequela  of  whooping-cough,  22 
tough  expectoration  with,  166 
value  of  pulse  in  cases  of,  253 
venous  engorgement  from,  261 
vesicular  breathing  diminished  in, 

145 
vicarious,  85 

downward    displacement    of 

lung  boundary  in,  136 
how  developed,  87 
no  expiratory  dyspnoea  with, 

100 
on  left  side,  difficulty  in  de- 
termining location  of  heart 
in,  211 
vital  capacity 'of  lungs  in,  164  , 
weakening    of    heart- sound  in,, 

219 
with     pleuritis,     friction  -  sounds 
with,  156 
Emphysematous  thorax,  83,  85 
Emprosthotonus,  539 
Emptying  of  stomach,  dangers  of,  357 
Empyema,  amount  of  expectoration 
in,  168 
crystals  in  sputum  of,  180 
hsematoidin  in  sputum  of,  172 
necessitatis,  102 
pulsans,  102,  204 

difficulty    in    distinguishing 
from  apparent  enlargement 
of  heart,  210 
pulsation  in,  near  the  heart,  204 
purulent  sputum  in,  169 
staphylococcus  pyogenes  found  in, 

603 
tuberculous,  161 
tyrosin  in  sputum  of,  182 
Encapsulated  pleurisy  defined,  129 
Encephalitis     in     children,    choreic 
movements  with,  535 
neuro-retinitis  with,  601 
ushered  in  by  epileptiform  spasm, 
533 
Encysted  inflammatory  exudation  in 

abdomen,  317 
Endemic  diseases,  21 


INDEX. 


635 


Endocardial  murmurs,  loudness  of,  to 
what  due,  223 
sounds  felt,  204 
whizzing,  227 
Endocarditis  a  cause  of  insufficiency, 
194 
of  stenosis,  194 
aortse,  embolus  of  retinal  artery 

in,  562 
embolus  of  central  retinal  artery 

in,  602 
hajmaturia  with,  417 
retinal  hemorrhages  in,  602 
sequela  of  scarlet  fever,  22 
streptococcus  pyogenes  with,  603 
ulcerative,    staphylococcus    pyo- 
genes in,  603 
valvular,  relation  of,  to  disease  of 
the  brain,  576 
Engorgement,  dropsy  of,  440 

of  kidney,  haematuria  with,  417 
of  liver,  surface  of,  325 
of  spleen,  335 
venous,  effects  of,  260 

thrombosis  in  cedema  of,  268 
Enteralgia,  simulation  of,  19 
Enteritis,  amoeba  coli  in  stools  of,  391 
color  of  stool  in,  373. 
consistence  and  form  of  stool  in, 

371 
forms  of  fat  found  in  feces  in,  386 
mycotic,    ptomaines   in  intestine 

in,  432 
poor  absorption  of  fat  in,  371 
Enteroliths,  from  vermiform  appendix, 

376 
Enuresis  from  phimosis,  580 

nocturnal,  400,  579 
Eosin,  staining  of  white  corpuscles  of 

blood  with,  279 
Eosinophile  white  corpuscles  in  leu- 
kaemia, 279 
Epigastric  angle,  82 

in  emphysematous  thorax,  83 
in  phthisical  thorax,  84 
pulsation    not  to  be  confounded 
with  simple  aortic  pulsation,  204 
Epigastrium  defined,  297 
illustrated,  298 
portion  of  liver  in,  320 
projection  of,  in  enlargement  of 

liver.  321 
protrusion  of,  in  inspiration,  90 
pulsation  in,  204 
Epilepsy,  acetonuria  after  attacks  of, 
448 


Epilepsy,  albuminuria  with,  435,  441 
clonic  spasms  in,  532 
convulsions  of,  37 
cutaneous  hemorrhages   from  at- 
tacks of,  582 
cyanosis  in,  44 
differential     diagnosis     between 

genuine  and  symptomatic,  533 
disturbance  of  consciousness  in, 

470 
dyspnoea  in,  95 
fever  with  attacks  of,  575 
glycosuria  after  attack  of,  443 
hyperosmia  and  parosmia  as  an 

aura  in,  574 
involuntary  passage  of  semen  in, 
534 

of  urine  in,  580 
Jackson's  (partial  or  cortical),  533 

described,  633 
opisthotonus  with  convulsions  of, 

468 
(petit  mal)  syncope  with,  471 
spasm, or  convulsion, described, 432 
spermatozoa   in   urine    after    at- 
tacks of,  421 
tinnitus  aurium  sometimes  as  an 

aura  a  precursor  of,  573 
tonic  and  clonic  spasm  of  thoracic 

muscles  in,  540 
traumatic  and  reflex,  530,  533 
wounding   of  tongue  during  at- 
tacks of,  287 
Epistaxis,  73 

Epithelial  casts,  forms  of,  in   urine, 
424 
illustrated,  424 
Epithelium,  ciliated,  transfer  of  mucus 
by,  167 
in  sputum,  176 
in  urine,  kinds  and  significance 

of.  420 
renal,  illustrated,  421 
Equilibrium,  an  act  of  coordination, 

527 
Equinia,  acute  nasal  catarrh  in,  74 
Erb,  normal  electrode  of,  502 

reference  to,   461,  469,  476,  498, 
501,  504,  508,509,510,511,512, 
514,  516,  517.520,521,523,524, 
525,  567 
Erb's  fine  electrode,  507 

point  in  brachial  plexus,  487 
supra-clavicular  point,  510 
Ergotism,  gangrene  in,  577 
Eructation,  odor  of,  359 


636 


INDEX. 


Erysipelas,  coccus  of,  161 

enlargement  of  spleen  in,  335 
fever  in,  65 
leucocytosis  in,  278 
recurrence  of,  22 
resembles  inflammation  of  strep- 
tococcus erysipelatosus,  604 
vomiting  in,  358 
Erythrodextrin  from  starch,  353 
Esbach's  albuminometer  described  and 

illustrated,  438 
Escherich,  reference  to,  388 
Eserine,  elFect  of,  on  pupil,  567 
Ether    poisoning,    cause  of  hsemato- 

jaundice,  47 
Ethmoid  nerve,  illustrated,  485 
Etiology,  value  of,  20 
Ewald,  reference  to,  349,  351,  354 
Exacerbation  of  febrile  disease  shown 

by  temperature,  65 
Examination,  electrical,  details  of,  507 
general,  divisions  of,  31 
method  of,  in  diseases  of  nervous 

system,  463 
of  patients   24 
of  the  blood,  270 
special,  scheme  for,  27 
Examining  electrode,  size  of,  502 
Exanthemata  from  poisons,  50 
Exanthematous  diseases,  49 

fevers,  enlargement  of  spleen  in, 
334 
Excesses,  venereal,  cause  of  disease,  21 
Excitability,    bilateral  variations   of, 
518 
increased  in  tetanus,  526 
lessened,  when  it  occurs,  525 
mechanical,  of  muscles  and  nerves, 

526 
of  nerve  (muscle),  degree  of,  505 
quantitative    and   qualitative,   of 
nerves  and  muscles,  516 
Excitement,  eftect  of,  on  amount  of 
urine,  401 
on  heart-sounds,  216 
on  pulse  in  fever,  240 
upon  pulse,  235 
headache  after,  483 
induces  perspiration,  37 
mental,  effect  of,  on  heart,  198 
heart   not  to    be    examined 
after,  201 
syncope  from,  471 
Exciting  causes,  effects  of,  on  chronic 
diseases,  21 
of  disease,  21,  22 


Exclusion,  determining  limits  of  liver 

by,  328 
Exertion,  albumin  in  urine  after,  437 
effects  of,  in  auscultation  of  heart, 
211 
on  action  of  heart,  198 
on  pulse  in  fever,  240 
upon  pulse,  235 
headache  after,  483 
heart  not  to  be  examined  after, 

201 
mental,  glycosuria  after,  443 
muscular,  a  cause  of  idiopathic 

hypertrophy,  196 
over-,   weakness  of  heart-sounds 

from,  218 
severe,  a  cause  of  emphysema  of 
skin,  56 
Exhaustion  which  accompanies  vomit- 
ing, 359 
Exophthalmia,  565 
Exophthalraus  paralyticus,  563 
Exotic  diseases,  21 

Expectoration  absent  when  there  is 
no  cough,  167 
defined,  167 
examination  of,  167 
general  characteristics  of,  168 
kinds  of,  168 
Experiment    to    illustrate    effect    of 
length  of  cylindrical  cavities  upon 
pitch  of  sound,  110 
Experimental  meal,  Ewald's,  349 
Jaworski's,  349 
Leube's,  347 

relative  merits  of  each,  349 
Expiration,  bronchial  breathing  usu- 
ally most  distinct  with,  147 
effect  of,  on  circulation  in  jugular 

vein,  262 
in  emphysema,  84 
muscles  of,  97 

position  of  liver  during,  320 
pressure  of  respiratory  air  in,  164 
prolonged,  in  commencing  tuber- 
culosis  of    apices  an  im- 
portant sign,  150 
when  occurs,  145 
role  of  the  abdominal  muscles  in, 

540 
sound  of,  bronchial  in  character, 
142 
Expiratory  bulging,  98 

dyspnoea  in  emphysema,  84 

relation  of,  to  emphysema,  85 
to  inspiratory,  100 


INDEX. 


687 


Expiratory  dyspnoea,  when  exists,  99 
pressure  greater  than  inspiratory, 

164 
valvular  sound  in  the  crural  vein 
in  health,  269 
Exploratory  puncture,  directions  re- 
garding, 162 
of  abdomen,  value  of,  318 
of  pleura,  how  performed,  160 
of  the  heart,  234 
use  of,  130 
Exposure  a  cause  of  disease,  21 
Extra-pericardial  friction  sounds,  233 
Extremities,    nerves   of,  motor   tracts 

of,  illustrated,  453 
Extremity,  lower,  muscles  of,  545 

muscles  of  the  upper,  540 
Exudation  depressing  the  diaphragm, 
128 
diagnosis  of,   from  transudation, 

160 
extent  of,  shown  by  area  of  dead- 

ness,  128 
in  abdomen,  value  of  measuring 

circumference  of,  316 
increase  of  chloride  of  sodium  in 

urine  with,  434 
inflammatory,  in  abdomen,  317 
kinds  of,  in  pleural  cavity,  161 
plegaphonia  over,  159 
pleural,  encapsulated,  128 

measurement   of  thorax   in, 
163 
pleuritic,  effect  of,  on  vocal  fre- 
mitus, 157 
or  pericardial,  conceals  apex- 
beat,  201 
purulent,  in  sputum,  167 
Eye,  affections  of,  in  diseases  of  the 
nervous  system,  561 
cystercerci  in,  from  taenia  solium, 

578 
determining  paralysis  of  muscles 
of,  564  I 

function  of  individual  muscles  of, 

564 
inflammation  and  ulceration  of, 

from  paralysis  of  nerve,  484 
movements  of,  paralpsis  of  mus- 
cles, 562 
muscles  of,  536 

significance   of  paralysis  of,  : 
564 
Eyelids,  dropsy  of,  in  kidney  disease, 
440  I 

Eyes,  how  closed,  536  I 


Eyes,  relation  of,  to  vision,  illustrated, 
570 
unequal  refraction  of  two,  567 


FACE,  motor  centre  for  lowe.  por- 
tion, 454 
muscles  of,  536 

three  most  distinct  points  upon, 
i         _     510 

Facial  nerve,  chorda  tympani  nerve 
joins  the,  461 
effects  of  paralysis  of,  536 
increased  mechanical  excita- 
bility of,  in  tetanus,  526 
lesion  of,  from  caries  of  pet- 
rous  portion   of  temporal 
bone,  469 
motor   tracts   of,  illustrated, 

453 
paralysis  of,  548 
paralysis,  diminished  secretion  of 
saliva  in,  578 
effect  upon  taste  in,  574 
hearing  in,  572 
reflex,  497,  499 
rheumatic,    partial   EaE,   in, 
525 
rheumatic  paralysis,  520 
sense  of  taste  in  anterior  portion 
of  tongue  affected  in  paralysis 
of,  461 
tract,   paralysis   of,   bone    reflex 
present  in,  500 
Faradic  battery,  secondary  or  induced 
current,   for  examining  nerves 
and  muscles,  501 
current  causes  tetanic  contraction, 
506 
comparative  unimportance  of 

the  poles,  504 
Erb's  fine  electrode  for,  507 
relation  of  total  strength  to 

galvanic  current,  514 
strength   of,   how  measured, 
502 
examination  of  nerve-muscle,  de- 
scribed, 512 
to  be  followed  by  galvanic, 
514 
excitability  of  the  two  sides  of  the 
body,  516 
Farado-culaneous     sensibility,     476, 

477 
Fasting  stomach,  gastric  secretion  in, 
346 


638 


INDEX. 


Fat,  absence  of,  34 

development  of,   in    diseases    of 

blood-making  organs,  41 
drops  of,  in  urine,  significance  of, 

420 
effect  of,  on  extent  of  abdomen,  309 
in   conjunctiva    not  to   be    con- 
founded with  jaundice,  45 
in  urine  after  fatty  food,  405 
lumps,  needle-shaped  crystals  in 

stools,  significance  of,  386 
people,  veins  of,  260 
striae  produced  by  accumulations 

of,  52 
variations  in  amount  of,  34 
Fatigue  a  cause  of  disease,  21 
Fatty  acids,  crystals   of,  in  sputum, 
184 
in  sputum  of  gangrene,  190 
degeneration  of  heart,  paleness  in, 
41 
of  kidney,  epithelium  found 
in  urine  of,  421 
heart,  Cheyne-Stokes  respiration, 
92 
Fauces,  vomiting  from  tickling  of,  358 
Favus  in  vomit,  366 
Fear  produces  perspiration,  36,  37 
Febrile    diseases     cause     change    in 
weight,  36 
exacerbation  shown  by  tem- 
perature in,  65 
haemic  murmurs  in,  229 
perspiration  in,  37 
pulse  in,  239 

subnormal  temperature  in,  63 
value  of  pulse  in,  253 
weakness  of  heart-sounds  in, 
218 
Febris  hepatica,  herpes  with,  50 

recurrens,  37 
Fecal  accumulation  in  stenosis  of  in- 
testine, 369 
odor  of  stool  masked  by  other  sub- 
stances in,  372 
vomiting  not  always  fatal,  364 
when  occurs,  364 
Feces,  balls  of,  in  intestine,  diagnosis 
of,  310 
Charcot-Leyden's  crystals  in,  181 
in  urine,  315 

involuntary  discharge   of,  in   at- 
tacks of  epilepsy,  534 
microscopical  constituents  of,  il- 
lustrated, 385 
examination  of,  method  of,  385 


Feces  mixed  with  blood,  significance 
of,  375 
physical  and  chemical  peculiari- 
ties of,  370 
section  on,  367 
Feculent  exudation  in  pleural  exuda- 
tion, 161 
odor  of  urine,  414 
Fehleisen,  reference  to,  427 
Fehling's  solution,  estimating  amount 
of  sugar  by,  446 
test  for  sugar,  compared  with 
polarizing  method    447 
Female  sexual  organs,  headache  with 

diseases  of,  483 
Ferment,  in   gangrene  of  lungs  and 

bronchitis,  190 
Fermentation,  alkaline,  in  urine,  from 
micrococci,  425 
ammoniacal,  of  urine,  effect  of,  402 
increased  formation  of  lactic  acids 
in  subacidity  of  stomach,  with, 
356 
in  dilated  stomach,  346 
in  intestinal  canal,  acid  reaction 
of  stool  in,  372 
alkaline  reaction  of  stool 
in,  372 
microorganisms    that    excite,   in 

stomach,  343 
of  contents  of  stomach  with  dila- 
tation of  stomach,  308 
of  urine  in  bladder,  cause  of  turbid 

urine,  412,  415 
test  for  sugar,  445 
Ferrocyanide    of   potassium   test  for 

albumin  in  urine,  436 
Fetor  of  breath,  285 
Fever.     Also  see  Temperature, 
acetonuria  in,  448 
albuminuria  with,  435 
alkalescence  of  blood  diminished 

in,  283 
anidrosis   of,   resists    therapeutic 

measures,  38 
brick- dust  sediment  in  urine  of, 

430 
casts  in,  422 

cause  of  increased  dyspnoea,  96 
chill  of,  phenomena  of,  40 
chloride  of  sodium  in  urine  dimin- 
ished in,  434 
chlorides  diminished  in,  60 
coating  of  tongue  in,  287 
continued,  sweat  diminished  in, 
38 


INDEX. 


639 


Fever,  continued,  urine  in,  426 

continuous,  significance  of,  587 

critical  purturbation  in,  68 

curve,  effect  of  antipyretics  on,  67 

dark  color  of  urine  of,  408 

defervescence  of,  67 

defined,  60 

delay  in  absorption  from  stomach 

in  cases  of,  355 
diaceturia  in,  447 
diminished  amount  of  urine  in, 

407 
disturbed  nutrition  in,  575 
effect  of,  upon  heart's  action,  201 
exacerbation  of,  62 
frequent  pulse  with,  238 
heart  sounds  strengthened  in,  217 
hectic,  68 

hyaline  casts  in  urine  of,  423 
in  connection  with  nervous  dis- 
eases, 575 
increase  of  urea  in,  433 

urobilin  in  urine  in,  48 
increased  frequency  of  respiration 
in,  94 
formation  of  CO2  in,  93 
intermittent    destruction   of   red 
corpuscles  in,  434 
herpes  with,  50. 
malarial,  defined,  70 
irregular  in  various  diseases,  71 
lips  in,  285 

mucus  in  urine  of,  416 
of  pus  formation  in,  68 
pulse  in,  240 
recurrence  of,  66 
recurrent,     microorganisms     of, 

found  in  blood,  281 
red  skin  in,  41 

tongue  in,  287 
relapsing,  leucocytosis  in,  278 
section  on,  57 
slow  pluse  in  critical  decline  of, 

237 
sound  heard  over  crural  artery  in 

high,  259 
subacidity  of  stomach  in,  356 
subnormal  temperature  in  crisis, 

63 
three  types  of,  62 
thrush  in,  288 
tracing  of  pulse  of,  247 
trembling  of  tongue  in,  287 
tremor  with  rapidly-rising,  531 
typical  course  of,  64 
uric  acid  increased  in,  434 


Fever,  urinary  products  increased  in, 
60 
urobilin  in  urine  in,  409 
variations  of  temperature  in,  63 
with  albuminuria,  441 
Fibres-elastic  in  sputum,  175 
Fibrillary  contractions,  530 

defined,  532 
Fibrin,  floccules   of,  in  the  fluid  from 
puncture  of  pleura,  160 
in  urine  in  hjematuria,  439 
Fibrinous  tubes  in  sputum,  172 
Fibroma  of  larynx  def^cribed,  597 
pedu^iculated,    in    larynx,   illus- 
trated, 596 
Fifth  nerve  illustrated,  485 
Filaria   sanguinis    hominis,  cause  of 
hsematochyluria,  283 
effects  upon  theurineand 

urinary  passages,  425 
illustration  of,  282 
Filehne,  reference  to,  190,  198 
Finger-percussion,  105 

advantages  over  hammer  per- 
cussion, 116 
how  done,  118 
-pleximeter   percussion,  105 
Fingers,  characteristic  positions  of  the 
hand  and,  in  paralysis,  544 
distribution  of  nerves  to,  485 
paralysis  of  the  muscles  of,  543 
Finkler  and  Prior's  spirals,  390,  607 
how  distinguished  from 

cholera  bacillus,  391 
illustrated,  391 
Fischer,  reference  to,  478 
Fischl,  reference  to,  177 
Fissure  of  anus,  pain  at  stool  in,  370 
of  Rolando  illustrated,  466 
of  Sylvius,  artery  of,  462 

effect  of  occlusion  of,  462 
Flechsig,  reference  to,  452,  535,  586 
Fleischl's  hsemometer  recommended, 

271,  276 
Flexibilitas  cerea  defined,  535 
Fluctuation    in    abscess  of  liver  and 
echinococcus,  326 
sign  of  fluid,  315 
Fliigge,  reference  to,  184,289,  604,  605 
Fluid,  nature  of,  in  plural  cavity,  by 

puncture,  160 
Fluids,  effect  of  drinking,  on  color  of 

urine,  402 
Folic  musculaire,  534 
Fontanelle,    cerebral  blowing   sound 
heard  while  still  open,  258 


640 


INDEX. 


Food,  albuminous,  source  of  uric  acid 
in  urine,  405 
certain  ones  which  cause  polyuria, 

406 
character  and  amount  of  stool  af- 
fected by,  370 
color  of  the  vomit  from  kinds  of, 

360 
effect  of,  upon  color  of  stool,  372 
oxalate  of  lime  in  urine  after  cer- 
tain foods  named,  430 
particles  of,  in  stools,  386 
tests   of  rapidity  of  passage  of, 

from  the  stomach,  354 
when  in  sputum,  167 
Foot  clonus,  499 

quaking  with,  531 
paralysis  of  muscles  of,  547 
phenomenon,  defined,  tested,  sig- 
nificance of,  499 
objection  to  ordinary  method 
of  examination,  501 
sole  of,  reflex,  495 
Foramen  ovale,  open,  systolic  venous 

pulse  with,  267 
Forearm,  paralysis  of  muscles  of,  543 
Forehead,  liow  wrinkled,  536 
Form,  knowledge  of,  section  on,  481 
of  expectoration,  168 
of  spinal  column,  467 
Fossa  infra-spinata,  77 

deadened  sound  over,  114 
of  Sylvius,  illustrated,  466 
supra-spinata,  77 
Fossae  on  front  of  thorax,  76,  81 
Fourth  ventricle,  455 
Frankel,  A.,  pneumonia  coccus  of,  188 

reference  to,  161 
Frankel,  B.,  reference  to,  297 
Fredericq,  reference  to,  2S6 
Fremissement  cataire,  227 
Fremitus,  laryngeal,  75 

vocal,  palpation  of,  described,  156 
Frequency  of  breathing,  anomalies  of, 

91 
Frerichs,  reference  to,  301,  443 
Frey,  reference  to,  246 
Friction,  sensible,  how  recognized,  155 
-sounds,  extra-pericardial,  233 
felt  near  heart,  204 
not  heard  if  fluid  is  present, 

156 
not  to   be   confounded  with 

moist  rales,  155 
over  peritoneum,  318 
pericardial,  230 


Friction-sounds,  pleuritic,  described, 
155 
sometimes  a  favorable  sign, 
indicating     absorption    of 
fluid,  156 
when  occur,  156 
Friedlander,  pneumonic  coccus  of,  188 
Friedreich,  reference  to,  180, 191,  267, 

268,  269 
Friedreich's    change    of    sound    de- 
scribed, 113,  133 
Frontal  convolution,  left  third,  motor 
speech-centre,  555 
third,  blood  supply  of,  462 
lobe  illustrated,  466 
Frothy  sputum,  169 
Fruity  odor  of  urine,  414 

-  when  occurs,  414 
Fuliginous  deposit  on  lips  in  fevers, 

285 
Fulness  of  veins  increased,  260 
Functional  disease  of  nervous  system, 
sudden  return    to  normal  con- 
dition, a  certain  sign  of,  587 
neurosis,  analgesia  in,  479 
Fundus  oculi,  changes  in,  in  diseases 
other  than  nervous,  601 
changes   of,  in   nervous  dis- 
eases, 600 
of  stomach,  anatomical  relations 
of,  299 
position  of,  298 
Fungi  found  in  urine,  425 
in  sputum,  174,  183 
pathogenic,  section  on,  389 
spores  of,  in  feces,  when  found,  388 
Funke,  reference  to,  429 
Funnel-breast,  cause  of,  89 

described,  88 
Fiirbringer,  reference  to,  182 
Furuncles,   staphylococcus   pyogenes 
found  in,  603 


GABETT,  reference  to,  187 
Galacturia,  412 

produced  by  filaria  sanguinis, 
425 
Gall-bladder,  distended,  when  felt,  322 
emptying  of,  by  pressure,  326 
enlargement  of,  331 
normal  and  pathological  con- 
dition of,  326 
obstruction  of,  a  cause  of  en- 
larged liver,  322 
position  of,  320 


INDEX. 


641 


Gall-bladder,    suppuration    of,   gall- 
stones in  stools  from,  376 
-stones  a  cause  of  jaundice,  47 
accompanied    by   chill    and 

fever,  64 
appearance  of,  described,  376 
in  feces,  how  to  find,  376 
sometimes  can  be  felt,  326 
Gallop  rhythm  of  heart  described,  220, 

221 
Galvanic  battery,  constant  current  of, 
for  examining  nerves  and  mus- 
cles, 501 
current,  a  strong,  should  never 
be  used  upon  head,  511 
effect  of,  only  at  closing  and 

opening  of  current,  506 
how  to  distinguish  the  poles 

of,  504 
measure  for  strength  of,  502 
must  not  have  too  small  an 

electrode,  502 
normal  electrode  for,  507 
quality  of  reaction  with,  506 
relation  of,  to  total  strength 

of  faradic  current,  514 
used  in  determining  the  con- 
ductive resistance,  512 
examination,  how  conducted,  515 
methods,  and  explanation  of 

terms  used,  506 
should  always  follow  the  fa- 
radic, 514 
muscular  i-eaction,   normal,  dia 
grammatic    representation    of, 
519 
resistance,  476 

stimulation,     qualitative     irrita- 
bility of  muscles,  518 
tetanus,  505 
Galvanometer,  absolute,  503 

damping  of  vibrations  of,  515 

Edelraann's,  518 

limits  of  exactness  of  results  from, 

504 
time  when  to  be  read,  512,  515 
Ganglia  of  anterior  horn,  456 
Ganglion,  acoustic,  461 
geniculate,  461 
spheno-palatine,  461 
Gangrene,   infusoria    in    sputum    of, 
.     183 

odorless,  171 

of  lung,   crystals  in   sputum   of, 
180,  181 
effect  on  thorax,  87 


Gangrene  of  lung,  elastic  threads  in 
sputum  of.  177,  179 
fatty  acids  in  sputum  of,  190 
ferment  in,  190 
fetid  sputum   in,    described, 

174 
micrococci  in  sputum  of,  189 
mucus  in  three  layers  in,  169 
odor  of  sputum  in,  171 
relation  of,  to  brain  disease, 

576 
rupture  into  oesophagus,  296 
spontaneous,  in  neuroses,  577 
starch  corpuscles  in  sputum   of, 
180 
Gartner,  reference  to,  389 
Gas  in  stomach  and  intestines  some- 
times gives  a  lung-sound,  113 
intestinal,  effect  on  movements  of 

diaphragm,  90 
sound  on    percussing  over  cavity 
containing,  109 
Gastric  crises  defined,  578 

juice,  coagulating  effect  of,  353 
secretions,  accumulation  of,  346 
Gastritis,   vomiting  of  pus  in  phleg- 
monous, 364 
Gastro-duodenal  catarrh,  46 
Gastroxia,  361 
Gastroxynsis,  361 
Geigel,  reference  to,  267 
Geisler,  reference  to,  436 
Geniculate  ganglion,  461 
Genital  apparatus,  disturbance  of,  sec- 
tion on,  580 
Gerhardt,  reference  to,  125,  132,  191, 

259,  414 
Gerhardt's  change  of  sound  described, 

133 
Gestures  an  acquired  faculty,  549 
Glanders,  bacilli  of,  found  in  blood, 

282 
Glands,  enlarged,  compression  of  bron- 
chi by,  43 
Gleet,  diplococcus  in  urine,  427 

may  be  due  to  tuberculosis,  426 
Glioma,  usually  single,  585 
Glossitis    cause    of    enlargement    of 

tongue,  286 
Glosso-pharyngeus  nerve,  461 
Glossy  skin,  581 

Glottis,  dilators  of,  paralysis  of,  99 
spasm  of,  cause  of  cyanosis,  43 
due  to  eruption  of  teeth,  286 
muscles  of,  597 
vibrations  of,  in  phonation,  157 


41 


642 


INDEX. 


Glycosuria,  after  poisoning  with  va- 
rious substances  named,  443 
in  disease  of  oblongata,  579 
when  occurs,  443 
Glyksemia,  polyuria  due  to,  407 
Gmellin's  test  for  bile  in  urine,  442 
Goll,  columns  of,  459 
Gonococci  illustrated,  427 
in  pus  of  gonorrhoea,  427 
stains  of,  427 
Gonorrhoea,  coccus  of,  604 

haematuria  from,  417 
Goose's  throat,  a  condition  of  arteries, 

256 
Gorges,  reference  to,  404 
Gottstein,  reference  to,  595 
Gout,  neuralgia  in,  483 

uric  acid  found  in  blood  in,  283 
often  diminished  during 
attack  of,  434 
Gouty  diathesis,  increase  of  uric  acid 

in,  434 
Gram,  reference  to  method  of  staining, 

188,  189,  190,  282,  603,  604,  605 
Granular  casts,  generally  are  hyaline, 
424 
illustrated,  424 
Grape  sugar  in  urine,  when  it  occurs, 

443 
Graphic  communication,  disturbances 

of,  549 
Gray  substance  of  spinal  cord,  destruc- 
tion of,  results  of,  491 
Greater    circulation,    perspiration    in 
engorged  condition  of,  37 
slowing  of,  a  cause  of  cya- 
nosis, 44 
Griesinger,  reference  to,  382 
Guaiac,  tincture  of,  test  for  bile  pig- 
ment, 441 
Gummata,  change  in  shape  of  liver 
from,  325 
of  larynx,  595 
syphilitica,  in  larynx,  596 
Gums  and  teeth,  examination  of,  285 
Giinzburg,  reference  to,  352 
Gutbrod,  reference  to,  199 


TJABITATION,  a  cause  of  disease, 

Habits,  a  cause  of  disease,  21 
Habitual  headache,  hereditary,  483 
Hseraatemesis  described,  361 

diseases  with  which  it  occurs,  362 
Htematin,  absorption  bands  of,  272 


Hsematin  in  solution,  test  for,  441 
Hsematoidin,  46 

casts  mixed  with,  in  urine,  424 
crystals  of,  in  sputum,  180 

in  urine,  432 
in   lungs    of  patients   who  have 

died  from  heart  disease,  177 
in  sputum,  172,  176 
Hsemato-jaundice,  47 
Hsematoma  of  dura  mater,  inequality 

of  pupils  in,  567 
Haematuria,  410,  416 
albumin  with,  441 
due  to  strangulus  gigas,  425 
fibrin  in  urine  in,  439 
from  distoraa  haematobium,  425 
produced    by    filaria    sanguinis, 

425 
use  of  microscope  in,  418 
when  occurs,  417 
Hsemic  murmurs,  229 
Hsemin,  crystals  of,  illustrated,  363 

test  for,  363,  364,  375,  442 
Haemochromometer,    instrument    for 
estimating  number  of  red  corpuscles 
in  blood,  271 
Haemoglobin,  absorption  band  of,  273 
amount  of,  diminished  in  anaemia 
and  chlorosis,  275 
diagnostic  importance  of,  270 
appearance  of,  as  a  sediment  in 

urine,  419 
approximative   determination    of 

amount  of,  271 
casts  of  lumps  of,  424 
diminished    in    blood    in   oligo- 
cythsemia,  275 
poikilocytosis  with,  277 
exact    quantity    of,    only   deter- 
mined by  quantitative  spectrum 
analysis,  272 
in  separate  corpuscles  may  be  in- 
creased, 277 
loss  of,  cause  of  paleness,  40 
scale   for    estimating   percentage 

of,  in  blood,  272 
tests  for,  441 

urine  to  be  examined  for,  when 
no  corpuscles  are  found,  418 
Haemoglobinaemia,  46,410 
color  of  blood  in,  271 
examination  of  blood  in,  271 
value  of   spectroscopic  examina- 
tion of  blood  in,  272 
Haemoglobinuria,  410,  419 
albumin  with,  441 


INDEX. 


643 


Hsemometer,  Fleischrs,recommended, 

271,  276 
Hsemophile,  haematuria  in,  417 
Haemoptysis,  caution  against  speaking 

in,  159 
Haeser,  reference  to,  412 
Hair,  growth  of,  583 
Half-moon-sliaped  space  (Traube)  de- 
defined,  127,  128, 137, 
299,  300,  306,  329,  333 
diminished  by  enlarged 
spleen,  339 
by  exudation,  307 
encroached  upon  by  en- 
larged liver,  331 
in  examining  the  spleen, 

337 
outer  boundary  of,  found 
by  spleen,  333 
Hallervorden,  reference  to,  449 
Hallucinations   of  sight   in  delirium 

tremens,  471 
Hammer-pleximeter  percussion,  105 
Hammond,  W.  A.,  reference  to,  535 
Hand  and  fingers,  characteristic  posi- 
tions of,  in  paralysis,  544 
distribution  of  nerves  to,  485 
importance  of  knowledge  of  mus- 
cles of,  and  their  innervation, 
545 
mode  of  examination  in  paralysis, 

544 
nerves  of,  485 

paralysis  of  muscles  of,  543 
Hartnack,  reference  to,  175,  181,  185, 

281 
Hauser,  reference  to,  184 
Hawking  described,  166 
Hayem's  counting  chamber  described, 

274 
Head  and  neck,  points  of  electrical 
irritation  upon,  illustrated,  508 
a  strong  galvanic  current  should 

never  be  used  upon,  511 
distribution  of  cutaneous  sensitive 

nerves  upon,  illustrated,  485 
nerves  of,  484 
nervous  pain  in,  466 
Headache,   circumscribed,  when  dis- 
ease causing  it  is  so,  482 
from  uraemia,  440 
significance  of,  482 
unilateral  (migraine),  483 
Health,  patellar  tendon  reflex  always 

present  in,  499 
Hearing,  centre  of,  460 


Heart,  action  of,  increases  perspira- 
tion, 37 
interfered   with  by  pressure 

on  diaphragm,  40 
rapidity  and  strength  of,  212 
anatomy  of,  191 
apparent  enlargement  of,  209 
auscultation  of,  211 
-beat  not  to  be  confounded  with 

apex  beat,  201,  203 
boundary  between,  and  lung  illus- 
trated, 304 
caution  regarding,  when  making 

exploratory  puncture,  162 
change  in  form  of,  196 
in  systole,  198 
chronic  diseases  of,  paleness  in,  41 
subnormal    temperature 
with,  64 
-deadness,  boundaries  of,  124 

diminished  with  extension  of 

lung  boundaries,  136 
small    when    lungs  are    ex- 
panded, 136 
degeneratian   of,  weakens   apex- 
beat,  201 
diminished    work     of,    weakens 

apex-beat,  201 
disease,  Cheyne-Stokes  breathing 
in,  92 
development  of  fat  in,  41 
dyspnoea  in,  96 
effects     of,     on     circulation 

through  lungs,  44 
hsematoidin  in  the   lungs  of 
patients    who    have    died 
from,  177 
importance  of   second    pul- 
monary sound  in,  218 
infarction  of  spleen  from,  335 
inherited,  20 
pulse  in,  239 
with  effusion,  33 
with     slight    compensation, 
gallop  rhythm  with,  221 
dislocation  of,  199 
displaced  by  exudation,  128 
displacement  of,  by  tumors,  255 
disturbed  in  chronic  jaundice,  47 
-dulness,  absolute,  205 
area  of,  enlarged,  208 
diminished,  210 
displacement  of,  210 
parietal  area  of  heart,  204 
relative,    defined,    205,   207, 
208 


644 


INDEX. 


Heart-dulness,    size    and    diagnostic 
value  of,  207 
enlarged,  1  arger  parietal  area  with, 

197 
enlargement  of,  cause  of  expan- 
sion of  chest,  86 
diagnosis  of,  200 
effect  on  apex,  199 
left,    makes  the  half-moon- 
shaped  space  smaller,  806 
pulsations  at  base  of,  in,  203 
simulated,  197 
examination  of,  191 
excited   action  of,  in    Basedow's 
case,  201,  259 

in  nicotine  poisoning,  201 
exploratory  puncture  of,  234 
failure.     Also  see  Heart,  weak. 
Cheyne-Stokes  breathing  in, 

92 
confused  sounds  in,  212 
diagnostic    value    of    heart- 
sounds  in,  217 
due  to  disease  of  its  muscle,  40 
dyspnoea  in,  96 
gallop  rhythm  a  sign  of,  221 
pulse  in,  240 

lowering  of  temperature  in,  71 
first  sound  a  mixed  one,  214 

doubled,  216 
hsematoidin  in  sputum  in  disease 

of,  172 
hypertrophy  and  dilatation,  area 
of  dulness  enlarged  in,  208 
of,  pulse  in,  244 
or  dilatation    of,   not  to   be 
mistaken   in  retraction  of 
lung,  137 
other  than  valvular,  196 
increased  labor  of,  measured  by 

specific  gravity  of  urine,  413 
inspection  and  palpation  of,  197 
-liver  boundary  of,  329 
location   of,  in   side   position   of 

patient,  193 
mechanical  displacement  of,  87 
method  of  percussing,  208 
movement  of  blood  in,  193 
murmurs,  localization  of  223 

organic    distinguished    from 
inorganic,  230 
endocardial,  defined,  221 
relation  of,  to  time  of  action 

of  the  heart,  224 
transmission  of,  228 
when  heard,  222 


Heart  muscle,  diminished  amount  of 
urine  in  diseases  of,  407 
weakness  of  sounds  in  paral- 
ysis of,  218 
nervous  affections  of,  in  connec- 
tion with  disease  of  the  nose,  575 
neuroses,  577 

normal  percussion  figure  of,  205 

organic    disease    of,    palpitation 

and  pain  with,  577 

murmur  of,  219 

paleness  a  symptom  of  disease  of, 

40       _ 
palpitation  of,  in  mitral  defects,  240 

nervous,  201 
parietal  area  of,  changed  by  dis- 
location of,  211 
percussion  of,  204 
physical  phenomena  of,  193 
place    of,    makes   asymmetry    of 
sound  on  right  or  left  side  of 
chest,  121 
points  of  election  for  auscultating, 

213,  214 
position  of,  191 

in  children,  192 
powerful    action    of,   a  cause    of 

thoracic  pulsation,  102 
pressed  upon  by  meteorism,  309 
projection  of  neighborhood  of,  202 
pulsations  at  base  of,  203 
of,  palpation  of,  102 
pulse  in  valvular  disease  of,  240 
relation  between  size  and  energy 
of  action  of,  201 
of,  and  area  of  dul- 
ness, 205 
of,  and  parietal  por- 
tion, 196 
of,  to  diseases  of  the  brain, 

576 
of,  to  lungs,  79 
relative  deadness  of  sound  over, 

124 
representation  of  action  of,  215 
resistance  of,  205,  208 
simple  dilatation  of,  196 
slow  pulse  in  certain  conditions 

of,  237 
■sound,  metallic,  in  pneumo-peri- 

cardium,  210 
-sounds  doubled,  219 

metallic,  explained,  221 
normal,  described,  212 
variations  of,  216 
origin  of,  212 


INDEX. 


645 


Heart-sounds,  pathological  changes  in, 
216 
strengthened,     heard     over 

larger  area,  217 
tone  of,  variations  of,  216 
weakening  of  individual,  219 
when  weakened,  218 
strength  of,  estimated  by  pulse,  240 
value  of  absolute  dulness,  207 
of  pulse  in  displacement  of, 
253 
in  showing  complicating 
disease  of,  253 
valvular  disease  of,  enlargement 
of  liver  with,  324 
sequela  of  rheumatism,  22 
venous  engorgement  from  defect 

of  right,  261 
weak.     Also  see  Heart  failure, 
area  of  dulness  enlarged  in, 

209 
murmurs  indistinct  in,  223 
thrombi  in,  a  cause  of  em- 
boli. 576 
with   dilatation,    a   cause   of 
insufficiency,  194 
weakness,  character  of  pulse  in, 
243,  244 
Hearing,  importance  of,  determining 
disease  of,  572 
morbidly  acute,  672 
place  of,  in  speech,  550 
subjective  sensibility  of,  when  oc- 
curs, 572 
testing  of,  571 
Heat  induces  jjerspiration,  37 

sensations  of,  577 
Heaving,  strong  apex-beat,  200,  201 
Hebetude,  tongue  often  left  protruding 

when  there  is,  287 
Hectic  fever,  68 

in  tuberculosis,  42 
Hegar,  reference  to,  311,  398 
Height,  relation  of,  to  weight,  35 
Heitzmann,  reference  to,  590 
Heller,  reference  to,  378,  379,  383,  384 
Heller's  test  for  blood  pigment,  441 

for  hsemin,  364 
Heraatemesis  with  pulmonary  hemor- 
rhage, 167 
Hemialbuminose  in  urine,  435.  439 
Hemialbumose,  a  rare  constituent  of 

urine,  439 
Hemiansesthesia,  460,  461 

associated  with   unilateral  anos- 
mia, 573 


Hemiansesthesia   defined,   and   when 
occurs,  479 
in  gross  hysteria,  534 
Hemianopsia,  460 
cortical,  568 
homonymous,  defined,  569 

illustrated,  570 
phenomena  of,  571 
Hemiathetosis   occurs  in  same  loca- 
tions as  hemichorea,  535 
Hemichorea,  535 

Hemicrania,  one-sided  redness  of  face 
in,  42 
unilateral    redness   of   head    in, 
577 
Hemidrosis  defined,  37 

in  Basedow's  disease,  38 
Hemiopia,  460 
Hemiplegia,  457,  494 

arthropathia  in  old,  583 

ataxia  in  some  cases  of,  529 

cruciata,  456,  489 

decubitus  in,  582 

defined,  489 

dorsal  flexion  of  foot  with,  535 

hemichorea  a  forerunner  or  result 

of,  535 
right,  illustrated,  453 

-sided,  aphasia  with,  555 
Hemisphere,  right,  has  nothing  to  do 

with  speech,  555 
Hemisystole,  double  positive  venous 
pulse  in,  267 
explained,  202 
Hemoptysis  defined,  170 
Hemorrhage,  bloody  color  of  sputum 
from,  170 
cause  of  urobilin-icterus,  48 
cerebral,  effect  on  breathing,  91 
most  frequent  in  the  region 
supplied    by    the    middle 
cerebral  artery,  463 
slow  pulse  in,  237 
cutaneous,  contrasted  with  hyper- 
emia, 42 
effect  of,  on  amount  of  blood  in 

the  body,  270 
internal,  shovm  by  temperature, 
65 
sudden   fall   of  temperature 
with,  63 
long-continued,  a  cause  of  dropsy, 

53 
microcythsemia  after,  276 
of  lungs  caused  by  distoma  pul- 
monale, 183 


646 


INDEX. 


Hemorrhage  of  lungs,  diagnosis  from 

hemorrhage  of  stomach, 170 

starch  corpuscles  in  sputum, 

180 

of  pons  or  oblongata,  effect  of,  457 

of  stomach,  40 

microscope  useless  in,  365 
rectal,  stools  of,  described,  374 
retinal,  in  hemorrhagic  diathesis, 

562 
slow  pulse  with,  237 
source   of,   in    haimaturia,   diag- 
nosis of,  417 
subnormal  temperature  with,  63 
sudden  amaurosis  after  severe,  602 
symptoms  of,  40 
Hemorrhages,  cutaneous,  51 

distinguished    from    inflam- 
mations, 51 
in  jaundice,  47 
when  occur,  582 
Hemorrhagic  diathesis,  hemorrhage  of 
stomach  in,  362 
in  chronic  jaundice,  47 
retinal  hemorrhage  in,  562 
exudation  with  tubercle  and  car- 
cinoma of  pleura,  161 
infarction  of  kidney,  hsematuria 
with,  417,  418 
Hemorrhoids,  hemorrhage  from,  375 

pain  at  stool  with,  370 
Henle,  reference  to,  421,  486,  487,  641 
Hepatitis  cause  of  enlarged  liver,  322 
interstitial,  surface  of  liver  in,  325 
Hepatization    of  lung,  deadened   re- 
sonance over,  126 
Hereditary  disposition   to   headache, 
483 
taint  shown  by  funnel-breast,  89 
Heredity,  20 

Hering,  spectroscope  devised  by,  272 
Hernia,  examination  of  seats  of,  308 
Hernia  cause  of  pressure  on  nerves,  469 
Hernial    orifices  to  be  examined   in 

sudden  obstipation,  369 
Herpes  facialis,  50 

labialis  and  nasalis,  50 
zoster,  relation  to  nerves,  581 
Herringham,  reference  to,  437 
Heubner,  reference  to,  112, 135,  317 
Hiccough  defined,  540 

severe  in  abdominal  and  cerebral 
affections,  540 
High  lung  sound,  108 
Hildebrand,  reference  to,  356 
Hippocrates,  reference  to,  138,  156 


Hippocratic    succussion    confounded 
with  splashing  from"  stom- 
ach or  colon,  156 
described,  156 
Hirschmann,  reference  to,  503 
History,  clinical,  defined,  17 

previous,  what  comprises,  20 
Hoarseness,  how  caused,  598 
Hoffmann,  reference  to,  481, 482 
Homonymous  parts   to  be  tested  to- 
gether, 507 
Hooke,  reference  to,  138 
Hoppe,  reference  to,  190 
Horseshoe  kidney,  393 
Hour-glass  stomach,  302 
Huber,  reference  to,  428 
Hiifner,  reference  to,  434 
Hutchinson's  spirometer,  164 

teeth,  sign  of  congenital  syphilis, 

286 
triad,  signs  of  syphilis,  286 
Hyaline  casts  described,  and  when  oc- 
cur, 422 
granular  forms,  424 
illustrated,  423 
various  additions  to,  423 
Hydatid  vibration  with  echinococcus 
of  kidney,  396 
of  liver,  326 
Hydrsemia,  albuminuria  with,  435 
cause  of  oedema,  53,  54 
color  of  blood  in,  271 
leucocytosis  in,  278 
peculiarities  of  blood  in,  275 
polyuria  in,  406 
Hydrocephalus,  anosmia  with,  573 
choked  disc  with,  600 
head  unevenly  balanced  in,  539 
how  distinguished  from  rhachitis, 

464 
pressing  upon  third  ventricle,  601 
slow  pulse  with,  237 
with  macrocephalus,  464 
Hydrocyanic    acid,  color  of  blood  in 

poisoning  by,  270 
Hydronephrosis,  palpation  of,  396 

tenderness  in  inflammatory,  396 
Hydropericardium,  cause  of  weakened 
heart-sounds,  219 
increases   area   of  heart-dulness, 
209 
Hydroperitoneum.     See  Ascites. 
Hydro-pneumothorax,   splashing  in, 

233 
Hydrops  vesicae  fellese,  326 
Hydrothionic  urine,  415 


INDEX. 


647 


Hydrothorax,  diagnosis   by  explora- 
tory puncture,  129,  160 
Hyjosesthesia  defined,  477 
Hypacidity  of  gastric  juice,  effect  of, 

344 
Hyperacidityof  gastric  juice  shown  by 
microscopical  examination  of  vomit, 
365 
Hyperfesthesia  defined,  478 
Hyperidrosis  defined,  37 
Hypermetropia,  567 
Hyperosmia  in  hysteria  and  insanity, 

574 
Hyperpyrexia,  61 

Hypersecretion   of  gastric  juice  with 
vomiting  in  nervous  dyspepsia, 
361 
of  stomach  juices,  diagnosisof,  355 
with  hyperacidity  of  stomach,  361 
Hypertrophic  liver,  surface  of,  325 
Hypertrophy  combined  with  atrophy, 
493 
compensatory  of  one  division  of 

heart,  218 
idiopathic,  of  heart,  196 
of  a  ventricle  shown  by  strength- 
ening of  the   sound  of  corre- 
sponding valve,  217 
of  heart,  area  of  dulness  enlarged 
in,  208 
cause  of  projection  of  region 

of  heart,  202 
compensatory,  195 
degeneration  of,  weak  apex- 
beat  in,  201 
not  to  be  mistaken  in  retrac- 
tion of  lung,  137 
other  than  valvular,  196 
right  and  left,  251 
(with    dilatation),    diagnosis 
from  simple  dilatation,  196 
of  left  ventricle,  252 

aortic  second  sound  felfc 
in,  218 
pulsation  with,  258, 
254 
apex-beat,  when   absent 

in,  202 
capillary  pulse  in,  256 
heart  -  sounds    strength- 
ened in,  217 
polyuria  with,  406 
pulsations  in  arteries  in, 

256 
pulse  with,  242 
slow  pulse  with,  237 


Hypertrophy  of  muscles,  490,  493 
how  recognized,  494 
of  right  heart,   venous   engorge- 
ment with,  261 
ventricle   caused  by  emphy- 
sema of  lungs,  210 
pulmonary  second  sound 

felt  in,  218 
with      emphysema      of 
lungs,  204 
Hyphidrosis  defined,  37 
Hypnosis,  catalepsy  with,  536 

over-excitability   of  nerves    and 
muscles  in,  526 
Hypochondria,  oxalate  of  lime  in  urine 
of,  430 
phosphaturia  in,  432 
Hypochondriuni  defined,  297 
illustrated,  298 

left,   projection  of,   by   enlarged 
spleen,  334 
spleen  lies  in,  332 
projection    of  right,   in   enlarge- 
ment of  liver,  321 
right,  portions  of  liver  in,  319 
Hypodermic  syringe  used  in  explora- 
tory puncture  of  pleura,  160 
Hypogastrium  defined,  297 

illustrated,  298 
Hypoglossal  paralysis,  unilateral,  de- 
scribed, 537 
Hypoglossus,  paralysis  of  the,  548 
Hysteria,  absence  of  pharyngeal  reflex 
in,  497 
allochiria  in,  478 
anaesthesia  of  larynx  in,  576 

of  pliarynx  in,  577 
aphonia  in,  598 
catalepsy  with,  536 
disturbance  of  breathing  in,  576 
dumbness  after  an  attack  of,  548 
epithelium  in  bloody  sputum  of, 

176 
gross,  described,  534 
headache  with,  482 
hemianseatliesia  with,  479 
hemidrosis  in,  38 
hyperosmia  and  parosmia  in,  574 
hypersecretion  of  stomach  in,  357 
increased  tendon  reflex  in,  500 
laryngeal  spasm  in,  576 
loss  of  voice  in,  538 
narrowing  of  field  of  vision  in,  569 
nervous  cough  in,  165 
opisthotonus  with  convulsions  of, 
468 


648 


INDEX. 


Hysteria,  palpitation  of  heart  with,  577 
paralysis  in,  75 

of  diaphragm  in,  90 
peculiar  bloody  sputum  with,  171 
polydipsia  and  polyuria  with,  406 
relations  of,  to  sexual  organs  in 

women,  581 
sensibility  of  cranium  to  pressure 

in,  466 
spasms  in,  37,  494,  581 
tenderness  of  vertebrae  in,  467 
tonic  spasms  in,  532 
total  ageusis  points  to,  574 
tremor  with,  531 

unilateral  elevation  of  tempera- 
ture in,  71 
vomiting  in,  358,  361,  578 
Hysterical  and  epileptic  spasms,  dif- 
ference between,  633 
convulsions,  likeness  of,  to   epi- 
leptic, 533 
hemiansesthesia,  587 
paralysis,  EaR  not  present  in,  525 
persons,  over-excitability  of,  626 
signs,  534 
Hystero-epilepsy,  538 
cyanosis  in,  43 
distinguished  from  epilepsy, 

580 
stages  of,  634 

tongue  never'bitten  in  attacks 
of,  287 
-traumatic  neurosis,  analgesia  in, 
479 
paralysis,  493 
Hysterogenous  zones,  581,  687 
in  gross  hysteria,  534 

ICTERUS.     Also  see  Jaundice, 
bile  pigment  in  sputum  in,  172 
catarrhal,  oxalate  of  lime  in  urine 

of,  430 
hepatogenic,  color  of  stool  in,  373 

slow  pulse  in,  237 
neonatorum,  47 
urobilin  with,  411 
with  puerperal  pyaemia,  a  case  of, 
602 
Idiocy  defined,  472 
Idio  muscular    contractions    defined, 

526 
Idiopathic  migraine,  483 

neuralgia,  483 
Idiotism,  increased  secretion  of  saliva 

in,  577 
Idiots,  incontinentia  alvi  in,  578 


Idiots,  involuntary  discharge  of  urine 
by,  579 
skeleton  of,  33 
Ileo-csecal  region,  cooing  in,  in  ty- 
phoid fever,  312 
illustrated,  298 
-inguinal  nerve  illustrated,  487 
Ileus,  when  occurs,  364 
Iliac  fossa,  left,  pain  in,  with  dysen- 
tery, 308 
right,  pain  in,  with  typhoid 
fever,  typhlitis,  disease  of 
vermiform  appendix,  308 
regions,  pain   in,  due  to.  inflam- 
mation, 309 
vein,  oedema  of  legs  from   com- 
pression of,  314 
pressure    upon,  by  enlarged 
retro-peritoneal  glands,  341 
Imbecility  defined,  472 
Immediate  percussion  defined,  104 
Inacidity  of  gastric  juice,  345,  346, 356 
Inactivity,   atrophy  of,  defined,  a  re- 

rult  of  paralysis,  490 
Inanition,  acetonuria  in,  448 

slow  pulse  in,  237 
Incisura  cardiaca,  192 

and  parietal  relation  of  heart, 

197 
illustrated,  304,  327 
in  deep  inspiration,  125 
the  lung- heart  boundary,  122 
Incompensation,  difficulties  in  making 
diagnosis  when  present,  253 
of  heart  defined,  219 
Incontinence  of  urine,  400,  579 
Incontinentia  alvi,  when  occurs,  370, 

578 
Incubation,  period  of,  defined,  22 
Incubator,  testing  digestive  power  of 

gastric  juice  in,  362 
Indican,  coloringpigmentin urine,  402 
in  urine,  435 

described,  and  tests  of,  409, 

435 
when  occurs,  409 
Indifferent  electrode,  601 

where  placed,  602 
Indirect  percussion  defined,  104 
Inebriety  concealed,  20 
Infantile  paralysis,  493 
Infarction,    hemorrhagic,    of  kidney, 
hsematuria  with,  417,  418 
of  lung,  deadened  sound  over, 
127 
mucous,  mucus  in  feces  in,  387 


INDEX. 


649 


Infarction  of  lun^s,  bronchial  frothing 
in,  146 
dyspnoea  in,  95 
friction  sounds  with,  156 
weak  percussion  over,  115 
pulmonary,  bloody  sputum  in,  170 
Infection   distinguished   from   conta- 
gion, 22 
Infectious  diseases,  20 

acute,  delirium  in,  471 
headache  with,  483 
leucocytosis  in,  278 
ataxia  after  acute,  529 
disturbance  of  consciousness 

in,  470 
EaR  with  paralysis  in,  524 
enlarged  liver  with,  322 
enlargement  of  spleen  in,  334 
epileptiform    attacks  in   the 

beginning  of  acute,  533 
gallop  rhythm  a  sign  of  heart 

failure  in,  221 
glycosuria  in,  443 
hsemato-jaundice  in,  47 
haemoglobin    in    urine  with, 

411 
indicated  by  high   morning 

temperature,  64 
local  gangrene  in  acute,  577 
position  of  patient  in,  32 
respiration  in,  91 
slight  amount  of  vomit  in ,  360 
ulceration    of    larynx    with 

acute,  595 
value  of  pulse  in  beginning 

of,  253 
venous  thrombosis  in  severe 

acute,  268 
vomiting  in  beginning  of  cer- 
tain, 358 
influence,  neuralgia  from,  483 
Inflammation,  leucocytosis  in  all  kinds 
of,  278 
oedema  in  the  neighborhood  of, 

54 
of  chest,  pain  with,  101 
Infra -clavicular     spaces,    percussion 

note  over,  119,  120 
Infra-scapular  space,  77 
Infra-trochlear  nerve  illustrated,  485 
Infusoria  found  in  stools  of  diarrhoea, 
383 
in  sputum,  183 
Inguinal  region  defined,  297 
illustrated,  298 
pain  in,  from  psoas  abscess, 309 


Inhalation  of  dust  a  cause  of  disease, 

21 
Inherited  diseases,  20 

tendency,  20 
Injuries,     scars    from,    important    in 

nervous  diseases,  52 
Inner  capsule,  disturbance  of  vision 

by  lesion  of,  460 
Inorganic  murmurs,  229 

sediments   in   urine,   section   on, 
428-433 
most  frequent  fornds  in  urine, 
428 
Inosite  in  urine  in  diabetes  insipidus, 

447 
Insane,  incontinentia  alvi  in  the,  578 
involuntary  discharge  of  urine  by 
the,  579 
Insanitv,  hyperosmia  and  parosmia  in, 
57.4 
superacidity  of  stomach  in,  357 
Inspection  of  abdomen,  313 

of  intestine,  method  of,  308 
of  kidneys,  394 
of  stomach,  299 
of  thorax,  81 
of  veins,  260 

position  of  patient  during,  81 
Inspiration,  atelectatic  crepitation  in, 
154 
auxiliary  muscles  of,  96 
causes  rapid  emptying  of  veins, 

262 
deep,  effect  on  area  of  heart- dul- 

ness,  206 
forced,  cause  of,  100 
increased  circumference  of  thorax 

in,  163 
in  emphysema,  84 
jerking,  when  and  where  occurs, 

145 
pressure  of  respiratory  air  in,  164 
relation  to  pulsus  paradoxus,  263 
systolic      subclavian       murmurs 

heard  at  close  of,  259 
tonic  and  clonic  spasm  of  thoracic 

muscles  of,  in  tetanus,  540 
variation   of  pressure   during,  in 
pleural  and  subphrenic  cavity, 
317 
vesicular  breathing  only  heard  in, 
142 
Inspiratory  dyspnoea,  relation  to  ex- 
piratory, 100 
when  exists,  99 
with  emphysema,  100 


650 


INDEX. 


Inspiratory  pressure,  in  what  diseases 

diminished,  164 
Insufficiency  due  to  endocarditis,  194 
mitral,  systolic  venous  pulse  with, 

267 
of  aorta,  cause  of  pulsation,  254 

255,  256 
of  crural  vein  valve,  mur^nur  with, 

268 
of  tricuspid  valve,  positive  venous 
pulse  pathognomonic 
of,  264 
pulmonarv  second  sound 
in,  218" 
of  valve,  effect  of,  194 
valvular,  effects  of,  193 
Intelligence,  cloudiness  of,  in  ursemia, 
440 
development  of,  549 
Intensity  of  lung  sound,  108,  112 

of  sound  of  organs  containing  air 
explained,  106 
Intercostal    muscles,    atrophied   with 
lung  cavities,  98 
pain  in  trichinosis  of,  44 
paresis  of,  pulsation  with,  102 
nerves,  neuralgia  of,  in  tabes,  484 
neuralgia,  101 

increase  of  abdominal  reflex 
in,  496 
space,  second,  heart-sounds  heard 

at,  214 
spaces,  82,  84 

in  phthisical  thorax,  84 
Intermittent  fever,  69 

destruction  of  red  corpuscles 

in,  434 
herpes  with,  50 
increase  of  ch loride  of  sodium 

in  urine  in,  434 
malarial,  defined,  70 
range  of  temperature  of,  63 
sweat  in,  37 
Internal  capsule,  454,  461 

blood-supply  of,  462 
effect  of  lesion  of,  457 

of  local  disease  of,  459 
hemiansesthesia  with  deposits 
in,  479 
jugular    veins,    positive    venous 

pulse  in,  265 
organs,  disease  of,  effect  on  weight 
of  body,  36 
diseases  of,  effect  on  skin,  39 
effect  of  engorgement  of  veins 
on,  260 


Interscapular  space,  77 

percussion  note  over,  120 
Intestinal  bacteria  in  stools,  value  of, 
388 
canal,  portion  of,  in  stool,  from 

sloughing,  376 
catarrh,  acid  or  alkaline  stool  in, 
372 
bilious  stool  in,  373 
diffuse  dull  pain  with,  308 
due  to  tape-worm,  377 
infusoria  found  in  stools  in, 

383 
mucus  in  feces  in,  387 
mucous  stools  in,  374 
particles  of  food  in  feces  in, 
386 
contents,  decomposition  of  veget- 
able parasites  from,  388 
crises  defined,  578 
digestion  shown  by  stools,  366 
discharges,   frequency  and   char- 
acter described,  367,  368 
diseases  with  diminished  sweat,  38 
gas  hinders  action  of  diaphragm, 

90 
hemorrhage,  65 

phenomena  of,  40 
infarction  defined,  374 
irritation  from  worms,  a  cause  of 
epileptiform    attacks    in   chil- 
dren, 533 
peristalsis  sometimes  can  be  seen, 
309 
Intestine,    amyloid    degeneration    of, 
forms  of  fat  found  in  feces  in, 
386 
auscultation  of,  312 
invagination  of,  character  of  pain 

with,  308 
percussion  of,  311 
perforation   of,  cause  of  pneumo- 
thorax, 210 
resistance  of  fluid  in,  in  compari- 
son with  air,  315 
small,  mistaken  for  colon,  310 
Intestines,    closed   tympanitic    sound 
heard  over,  111 
disturbance   of,  from  venous  en- 
gorgement, 261 
examination  of,  308 

points  in,  370 
hemorrhage  from,  appearances  of 

blood  in,  375 
importance   of  emptying,  in  ex- 
amining abdominal  organs,  341 


INDEX. 


651 


Intestines,  inflating:,  for  purposes  of 
diagnosis,  312 
lung-sound,  wlien  heard  over,  113 
metallic  sounds  over,  112 
Invagination  of  intestine,  character  of 

pain  with,  308 
Invalidism,   venous  thrombosis    as  a 

result  of,  268 
Involuntary  discharges  during  an  at- 
tack of  epilepsy,  533,  534 
of  stool,  579 
Iodide  of  potassium  found  in  saliva, 
289 
in  urine  after  taking,  450 
Iron  colors  the  vomit  black,  360 
-dust,  detection  of,  177 

in  epithelial  cells  in  sputum, 

177 
in  sputum,  171 
solution  of  chloride  of,  a  test  for 
salicylic  acid  in  urine, 
354 
in  the  presence  of  alco- 
hol,   sugar,    and   acid 
salts,  351 
Irrigation  of  rectum,  311 
Irritability,  electrical  and  mechanical, 
of  muscles,  488 
of  nerves  and  muscles,  faradic  and 
galvanic,  representation  of,  521 
Irritation,  direct,  505 
indirect,  505 

of  nerves  from  pressure,  482 
peripheral,  sensitiveness  to,  472 
Ischiatic  nerve,  electrical  examination 

of,  511 
Ischuria  paradoxa,  580 
Itching  in  jaundice,  47 


JACKSON'S  epilepsy,  533 
described,  533 
Jaffe,  reference  to,  190 
Jaksch,    reference  to,   180,  272,  279, 
282.  283,  381,  382,  384, 385,  388,  423, 
424,  439,  444,  447,  448 
Jaundice,  45.     Also  see  Icterus, 
gall-stones  in  stools  with,  376 
itching  in,  47 
sometimes    caused   by  ascaris   in 

ductus  choledochus,  381 
sweat  in,  38 

with  engorgement  from  displace- 
ment of  right  kidney,  396 
with  puerperal  pysemia,  a  case  of, 
602 


Jaworski's  experimental  meal,  349 
Jendrassik,  reference  to,  501 
Jerking  breathing,  where  noticed,  143 
inspiration  distinguished  from  in- 
terrupted inspiration,  146 
when  and  where  occurs,  145 
Johnson,  reference  to,  436 
Joint  neuroses,  583 
Joints,   chronic   disease    of,   atrophy 
with,  493 
muscular  atrophy  from  diseased, 
lessened    excitability    without 
EaE,  625    ■ 
Jugular  vein,  right,  shape  of  opening 
and  its  relation  to  venous  hum- 
ming, 269 
veins,  phenomena  of  circulation 
in,  262 
Jurasz,  reference  to,  258 


KAHLER,  reference  to,  439 
Kaltenbach,  reference  to,  398 
Kan  n  en  berg,  reference  to,  183,  427 
KaSC,  520 

Kast,  reference  to,  434,  519,  520 
Keratin,   coating  for  pills,  in  testing 
rapidity  of  passage  of  food  from  the 
stomach,  354 
Keratitis,  parenchymatous,  a  sign  of 

syphilis,  286 
Kidnev,  amyloid,  casts   in   urine  of, 
422,  423 
contracted,  casts  in  urine  of,  422 
diminished  sweat  in,  38 
gallop  rhythm  of  heart  in,  221 
cedema  from,  is  fugitive,  440 
polyuria  with,  406 
relation  to  heart  disease,  576 
disease,  alkaline  vomiting  in,  366 
dropsy  of,  disease  of,  440 
engorgement  of,  casts  in  urine  of, 
422 
hyaline  casts  in  urine  of,  423 
lateritious  sediment  in  urine, 
430 
epithelium  from  in  case  of  dis- 
ease, 421 
fatty,  fatty  casts  in  urine  of,  423 
hemorrhage  of  the  pelvis  of,  diag- 
nosis of,  418 
hemorrhagic  infarction  of,  haema- 

turia  with,  417,  418 
horseshoe,  393 

large  white,  adipose   white   cor- 
puscles in  urine  of,  420 


652 


INDEX. 


Kidney,  large  white,  paleness  in,  41 
left,  adjacent  to  fundus  of  stom- 
ach, 299 
new  formations  of,  when  can  be 

felt,  395 
position  and  relation  of  right  and 

left,  392 
pulse  in  contracted,  244 
tenderness  in  tumor  of,  395 

of   region   of,  when    occurs, 
395 
tracing  of  pulse  of  contracted,  247 
tumors  of,  diagnosis  of,  397 

value  of  percussion  in,  397 
urine  from  only  one,  400 
vicarious-  action  of  one,  408 
wandering,  395 
Kidneys,anatomical  situation  of,411us- 
trated,  393 
anatomy  and  topography  of,  392 
engorgement      of,      albuminuria 

with,  435 
examination  of,  section  on,  392- 

451 
injury  to,  hsematuria  with,  417 
local  examination  of,  394 
location  of,  illustrated,  321 
pathological  condition  of,  394 
position  of,  79 

value  of  pulse  in  showing  compli- 
cating disease  of,  253 
Klemperer,  reference  to,  354,  437 
Knee-phenomenon,  synonym  for  pa- 
tellar reflex,  498 
Koch,  reference  to,  185,  390,  391 
Koch's  cholera  bacillus,  described  and 
illustrated,  389 
comma     bacillus     distinguished 
from   Finkler-Prior's   bacillus, 
607 
Kosselt,  reference  to,  190 
Kreatinin    hinders    examination    for 

sugar  in  urine,  405 
Krehl,  reference  to,  246 
Kronecker,  reference  to,  297 
Kiihne,  K.,  reference  to,  439 
Kiilz,  reference  to,  447 
Kuspmaul,  reference  to,  263,  301,  303, 

551,  552,  555,  556,  558 
Kypho-scoliosis,  467 

a   cause    of  hypertrophy  of 

right  ventricle,  196 
cases  in  which  spleen  can  be 

felt,  334 
deadened  sound  over,  114 
described,  88 


Kypho-scoliosis,  dyspnoea  from,  95 
Kyphosis,  467 

described,  88 

from  paralysis  of  erector  trunci, 
539 

LAACHE,   reference  to,   275,  429, 
430,  431,  432 
Lachrymal  nerve  illustrated,  485 
Lacing,    tight,    constriction   of   liver 

from,  323 
Lactic  acid,  excess  of,  in  stomach,  345, 
346 
fermentation,  effect  of,  343 
tests  for,  in  contents  of  stom- 
ach, 351 
Lactose  in  urine,  when  occurs,  and 

when  demonstrable,  447 
Laennec,  reference  to,  104,  138,  142, 

191 
Laennec's  pectoriloquy  described,  159 
Lagging  behind  in  paralysis  of  sen- 
sation, 485 
detected  by  palpation,  103 
in  breathing  described,  87,  91 
in  stenosis  of  a  bronchus,  98 
Lagophthalmus,  536 
Lalopathy,  548 
Lameness,  simulation  of,  19 
Landerer,  reference  to,  54 
Landois,  reference  to,  246 
Landois  &  Sterling's  Physiology,  re- 
ferred to,  505 
Lardosis    from    paralysis    of   erector 

trunci,  539 
Laryngeal  mirror,  591 

muscles,  action  of,  and  effects  of 

paralysis  of,  538 
spasm  defined,  576 
Laryngitis,  acute,  598 

circumscribed   phlegmonosa,   re- 
sults in  abscess,  594 
hypoglottica  illustrated,  593 

serious  nature  of,  594 
in  children,  593 
Laryngoscopic    examination    of    the 
larynx,  section  on,  589 
image,  reversal  of  parts  in,  591 
Larynx,  abnormal  redness  of  mucous 
membrane  of,  592 
casts  of,  in  croup,  172 
color  of  mucous  membrane  of,  591 
evidence  in,  of  pressure  by  tumors, 

255 
examination  of,  74 

for  recurrent  paralysis,  296 


INDEX. 


653 


Larynx,  inflammations  near,  cause  of 
cyanosis,  43 
laryngoscopic  examination  of,  sec- 
tion on, 539 
view  of,  590 
local  examination  of,  75 
nervous    diseases  in  which  it  is 

affected,  576 
normal  sound  over,  119 
open  tympanitic  sound,  when  it 

is  percussed,  110 
paralysis    of  various  muscles  of, 

and  results,  598 
pathological  condition  of,  592 
position  and  movements  of  por- 
tions of,  592 
sensitiveness  of,  a  cause  of  cough, 

165 
spasm  of  muscles  of,  597 
stenosis  of,  97 
tone  of  cough  in  ulceration  and 

stenosis  of,  166 
tympanitic  sound  over,  121 
ulceration  of,  a  cause  of  emphy- 
sema of  skin,  56 
what  to  observe  in  examining,  591 
Lateral  column  of  spinal  cord,  455 
Lateritious   sediment   in  urine,   402, 

429,  430. 
Laveran,  reference  to,  282 
Law  of  contraction,  518 
Lead  colic,  drawing  in  of  abdominal 
wall  in,  309 
pulse  with,  244 
tracing  of  pulse  of,  247 
headache  in  poisoning  with,  483 
neuralgia  from  poisoning  by,  483 
paralysis,  543 

EaR  in,  525 
poisoning,  21 

black  vomit  in  acute,  360 
cause  of  paleness,  41 
condition  of  teeth  in,  286' 
double  sound  heard  over  cru- 
ral artery  in,  259 
Leanness,  significance  of,  34 
Leg,  motor  centre  for,  454 

muscles  of,  and  their  paralysis,  546 
points  of  electrical  irritation  upon, 
514 
Legal,  reference  to,  448 
Length  of  Thorax,  163 
Lenticular  nucleus,  454 

blood-supply  of,  462 
disease  of  both  internal  seg- 
ments, with  chorea,  535 


Leo,  reference  to,  344  . 
Lepra,  21 

bacillus    described,    staining    of 
cultures  of,  606 
Leptothrix  buccalis  illustrated,  289 
in  urine,  428 
in  sputum,  175,  184 
pharvngomycosis     leptothricia, 
29  f 
Lesion,  location  of,  in  cortico-muscu- 

lar  tract,  effect  of,  456 
Lethargy,  defined,  470 
Letzerich,  reference  to,  190 
Leube,  reference  to,  302,  347. 355,  426, 

434,  445,  474 
Leube's    experimental  meal,  347,  348 
Leucin,  form  of,  in  urine,  431,  432 

when  occurs,  432 
Leuckart,  reference  to,  379 
Leucocytes  with  large  nuclei,  279 
Leucocythseraia,  relative,  275 
Leucocytosis    a    physiological   condi- 
tion  during  digestion,  278 
defined,  278 
Leukaemia,  41 

albuminuria  with,  435 

color  of  blood  in,  271 

crystals  in  blood  in,  181 

defined,  278 

greatest  enlargement  of  spleen  in, 

335 
hsematuria  in,  417 
red   corpuscles    diminished    and 

paler  in,  275 
retinal  changes  in,  602 
uric  acid  increased  in,  434 
use  of  microscope  in,  279 
various  forms  of,  279 
Levulose,  in  urine,  when  occurs,  447 
Lewis,  reference  to,  391 
Levden,    reference  to,  174,  179,  182, 

i90,  202,  267,  388 
Lichtheim,  reference  to,  53,  552,  553, 

555,  556,  558,  560 
Lieben,  reference  to,  448 
Liebermeister,  reference  to,  68, 238, 356 
Liebig,  reference  to,  434 
Lientery  stools,  372 
Life,  mode  of,  cause  of  disease,  21 
Light,  source  of,  for  laryngoscopic  ex- 
aminations, 589 
Lime,  oxalate  of,  in  sputum,  182 
Linea  costo-articularis,  332,  338 
Lines  drawn  on  thorax,  76 
Lingual  nerve,  chorda  tympani  in,  461 
Lintels,  185 


654 


INDEX. 


Lintels  of  tubercular  sputum,  177 
Lipsemia   defined    and  when   occurs, 

280 
Lipomatosis   cordis,   weak  apex-beat 

in,  201 
Lips,  color  of,  285 
Lipuria,  412 

occurs  in  chyluria,  447 
Literal   agraphia   an  aphasic  symp- 
tom, 561 
aphasia,  553,  556 
paragraphia,  561 
Litten,  reference  to,  427 
Liver,  acute  yellow  atrophy  of,  ecchy- 
mosis  in,  51 
anatomy  of,  319 
average  boundary  lines  of,  329 
cancer-navel  upon,  in  carcinoma, 

825 
cirrhosis  of,  tender  at  first,  324 
venous  engorgement  caused 
by,  262 
consistence  of,  in  various  diseases, 

326 
constricted,  sometimes  tender,  324 
deadness,  absolute,  124 
illustrated,  304 
in  right  mammillary  line,  108 
relative,    small   when    lungs 
expanded,  136 
downward  displacement  of,  128, 
321,  322,  324 
movement  of,  in  inspiration, 
322 
enlargement  of,  causes  and  signs 
of,  322 
displacement  from,  330 
due  to  venous  engorgement, 

260,  261 
effect  on  form  of  chest,  86 
makes     half-  moon  -  shaped 

space  smaller,  306 
projection  of  right  hypochon- 
drium  in,  321 
examination  of,  319 
granulated,  surface  of,  325 
inspection  of,  320 
-kidney  angle,  393 
location  of,  illustrated,  321 
lower  border  of,  rarely  felt,  321 
mobility  of  boundaries  of,  329 
mode  of  palpating  described,  266 
motions  during  breathing,  323 
organs  that  border  it,  320 
palpation  and  percussion  of,  323 
value  of,  332 


Liver,  pathological  conditions  of,  324 
relations   of  its   boundaries, 
329 
percussion  limits  of,  illustrated, 

326,  327,  328  , 

position  of,  78,  79 

and  boundaries  of,  illustrated, 

319 
as    affected    by   pleurisy  or 
pneumothorax  on  right  or 
left  side,  331 
pressure   upon,  from  meteorism, 

309 
proportion  of,  that  is  parietal,  320 
-pulse,  302 

arterial,  257 
venous,  266 
relative,  deadness  of  sound  over, 

124 
size  and  form  of,  324 
in  children,  320 
slight  projection  of,  in  children, 

320 
square  position  of,  330 
-stomach  boundary,  329 
surface  of,  in  various  diseases,  325 
that  is  displaced   downward  not 
to  be  confounded  with  enlarged, 
331 
tilting  of,  in  pleurisy,  199 
tumor  of,  306 

unequal  enlargement  of,  331 
wandering,  position  of,  322 

not     in     contact    with    dia- 
phragm, 322 
Lobes  of  the  brain,  upper  and  lower 
parietal,  temporal,  and  frontal, 
466 
of  the  lungs,  boundaries  of,  80 
Lobulated  liver,  from  deep  syphilitic 

scars,  325 
Loljus  paracentral  is,  454,  459 
Local  sense,  how  tested,  474 
Location  of  thoracic  contents   illus- 
trated, 319 
sense  of,  473 
Lofiier,  reference  to,  605,  606 
Logwood,  color  of  urine  after  taking, 

411 
Lordosis,  467 

from   weakness    or    paralysis    of 
muscles  of  spine,  467 
Louis,  angle  of,  defined,  76,  78,  81,  82, 
84 
in  phthisical  thorax,  84 
Lowenfeld,  reference  to,  523 


INDEX. 


655 


Lower  extremity,  illustration  of  cuta- 
neous nerves  of,  487 
nerves  of,  488 

points  of  electrical  irritation 
upon    the    back    of,    illus- 
trated, 513 
Ludovici,  angulus,  76,  78,  81,  82 
Ludwig,  reference  to,  198,  246 
Lumbar    enlargement  of  cord,  loca- 
tion of,  468 
Lumbo  inguinal  nerve  illustrated,  487 
Lung-cavities,   atrophy  of  intercostal 
muscles  in,  98 
bronchial  breathing  over,  146 
metallic  sounds  over,  112 
tympanitic  sound  with,  when 
communicating    with    air, 
131 
compression   of,  against  thoracic 
wall    increases    vocal   fre- 
mitus, 158 
by  large  exudation,  128 
from    high    position   of   dia- 
phragm, 317 
contraction  of  ,diiFerentiated  from 
primary  deformity  of  chest, 
88 
diminishes    area   of  spleen- 

dulness,  339 
left,  eflfect  on  heart,  203 
emphysema  of  cellular  tissue  from 

perforation  of,  56 
fistula,  sound  of,  defined,  153 
gangrene  of,  mucus  in  three  layers 

in,  169 
-heart  boundary,  122,  125 
-kidney  boundary,  123 
left,  lower  border  of,  boundary  of, 

125 
-liver  boundary,  122, 124, 125, 328, 

329 
overlaps  the   spleen  and  dimin- 
ishes area  of  dulness  over,  339 
retracted,  tympanitic  sound  with, 

111 
sequestra,  172 
shrinking  of  197 
-sound  defined,  108 
-spleen  boundary,  122,  124 
-stomach  boundary,  122,  124 
thickening  of,  ringing  rales  with, 

152 
tissue,  decreased  tension  of,  135 
in  sputum  in  abscess  of  lung, 

172 
no  irritative  cough  from,  165 


Lung  tissue,  relaxation  of  tympanitic 
sound  with,  130 
retracted,  noise  of  spun-top 

over,  135 
thickening      of,      bronchial 
breathing  in,  146 
Lungs,  abnormal  sounds  over,  125 
abscess  and    gangrene  of  elastic 
threads  in  sputum,  177 
hsematoidin  in  sputum,  172 
active  mobility  of,  125,  210 
amount    of     expectoration    from 

cavities  in,  168,  169,  175 
anatomical  boundaries  of,  78,  79 
auscultation  of,  138 
borders  of,  80 

boundaries  of,  changed,  136,  304, 
319 
rules  to  be  observed  in  deter- 
mining, 124 
brown  induration  of,  dyspnoea  in, 

96 
catarrh  of  larynx  in  disease  of, 

593 
chronic    diseases    of   subnormal 

temperature  with,  64 
consolidation  of  cyanosis  in,  43 
contraction  of,  a  cause  of  hyper- 
trophy of  right  ventricle,  196 
difficulties   in   determining  their 

boundaries,  123 
diminished  volume  of,  how  recog- 
nized, 137 
diseases  of,  form  of  thorax  in,  81 

which  cause  dyspnoea,  95 
disposition  to  disease  of  81 
disturbances    of   the    circulation 

through,  44 
dust  diseases  of,  21 
elasticity  of,  lost  in  emphysema,  84 
emphysema    of,   a   cause   of  dis- 
placement of  heart,  199 
weakens  apex-beat,  201 
examination  of,  76 
gangrene  of     Also  see  Gangrene, 

odor  of  sputum  in,  171 
hemorrhage    of,    in  tuberculosis, 

170 
large   cavity   in,    metallic  heart- 
sounds  with,  221 
lobes  of  boundaries  of,  80 
location  of  illustrated,  321 
lower  border  of,  in  children.  192 
relatively  deadened  sound 
over,  114 
boundary  of,  122 


656 


INDEX. 


Lungs,  normal  percussion  of,  bounda- 
ries of,  121 
sound  over,  119 
cedema  of,  bloody  sputum  with,  170 
dyspnoea  in,  95 
serous  sputum  a  peculiarity 
of,  169 
percussion  of,  described,  118 
posterior    boundaries    of,    illus- 
trated, 123 
pressure  upon,  by  meteorism,  309 
rapid  breathing  in  inflammation 

of,  94 
relation  of  disease  of,  to  certain 
brain  diseases,  576 
to  diaphragm,  80 
retraction  of,  measure  of  thorax 
in,  163 
near  the  heart,  137 
upward  displacement  of  liver 
with,  323 
shrinking  of,  a  cause  of  displace- 
ment of  heart,  199,  200,  211 
both       pulmonary       sounds 

strengthened  in,  218 
pulsations  at  base  of  heart  in, 
203 
starch  corpuscles  in  the  sputum 

in  hemorrhage  of,  180 
symptoms    of    hsematemesis    in 

hemorrhage  of,  167 
thickening    of,   deadened    sound 
from,  114 
feeling  of  resistance  with,  116 
metallic  rales  with,  150 
simulates  enlarged  heart,  209 
thoracic  boundaries  of,  77 
topographical  anatomy  of,  76 
tuberculosis  of,  see  Tuberculosis 
tumor  of,  peculiar  sputum  in,  171 
tumors  of,  deadened  sound  over, 

127 
value  of  pulse  in  showing  compli- 
cating disease  of,  253 
vital  capacity  of,  relation  to  size 

of  body,  164 
wounds  of,  a  cause  of  emphysema 
of  skin,  56 
Lupus,  may  be  the  cause  of  catarrh  of 

larynx,  593 
Luschka,  reference  to,  78,  79, 192,  319, 

321 
Lustgarten,  reference  to,  399,  427 
Lymphatic  glands,  blowing  murmurs 
over,  259 
leucocytosis  in  swelling  of,  278 


Lymphatic  glands  swollen  in  syphilis 

and  diphtheria,  290 
Lymphosarcoma  of  spinal  cord,  he- 

mialbumose  in,  439 
Lysis  defined,  67 
Lyssa,  increased  tendon  reflex  in,  500 


M-A  (milliamperes)  strength  of  cur- 
rent measured  in,  512,  515 
Macrocephalus    with  hydrocephalus, 

464 
Macrocytes,  defined,  occur  in  anaemia 

and  in  pernicious  anaemia,  276 
Maixner,  reference  to,  439 
Malaise,  from  uraemia,  440 
Malaria,  bacillus  of,  282 

diagnostic   value  of  temperature 

in,  64 
haemoglobin  in  urine  of,  411 
melanaemia  in,  280 
neuralgia  from,  483 
spleen  much  enlarged  in,  335 
Malarial  cachexia,  41 

intermittent  fever,  70 
Malignant  growths  cause  of  paleness, 
41 
pustule,  21 

examining  blood  for  micro- 
organism of,  282 
Mai  perforant,  defined,  582 
Mammillary    line    corresponds    with 
border  of  liver,  327 
edge  of  liver  at,  323 
variations  of,  77 
lines,  297 

defined,  76 
Manegegang,  534 
Mania,  with  uraemia,  440 
Manneberg,  reference  to,  399,  427 
Manometer,    use  of,   in   puncture  of 

cavity,  318 
Marasmus  defined,  35 
Marchiafava,  reference  to,  282 
Marching  a  cause  of  disease,  21 
Marey,  reference  to,  246 
Marie,  reference  to,  560,  583 
Martins,  reference  to,  199 
Masseter  spasm  in  trismus,  532 
Mastication,  difiiculty  of,  in  paralysis, 
537 
muscles  of,  536 
Matterstock,  reference  to,  259 
Maxilla,    superior,    nerve    supply    of 

mucous  membrane  of,  484 
Meals,  effect  upon  pulse,  235 


INDEX. 


657 


Measles,  49 

acute  nasal  catarrh  in,  74 

coin  shaped  sputa  in   bronchitis 

of,  169 
epileptiform   convulsions   in   the 

beginning  of,  533 
inflammation  of  larynx  in,  75 
petechise  in,  may  be  overlooked, 

51 
recurrence  of,  22 
Measurement  of  thorax  in'  aneurism 

of  aorta,  254 
Measuring  circumference  of  abdomen, 
value  of  316 
the  thorax,  162 
Meat-juice  stools  in  dysentery,  375 
Mechanical  EaR,  526 

irritation,  neuralgia  from,  483 
Median  nerve,  anaesthesia  in  the  re- 
gion of,  from  paralysis  of 
brachial  plexus,  487 
distribution  to  hand,  545 
illustrated,  486 
paralysis  of,  544 
Mediate  percussion  deiined,  104 
Mediastinal  emphysema,  crepitations 
of,  233 
pericarditis,  204 

tumor,  measurement  of  thorax  in, 
163 
producing  pressure-paralysis 

of  recurrent  nerve,  538 
swelling  of  cutaneous  veins 
over  sternum  sign  of,  262 
venous     engorgement    from, 
261 
tumors  affecting  larynx,  75 

displacement  of  the  heart  by, 

199 
effect  on  heart,  201 
Mediastinitis,    callous,    diastolic   col- 
lapse of  cervical  veins  in,  267 
effect  upon  venous  circulation,  263 
Mediastinum  displaced  by  exudation, 
128 
displacement  of,  how  recognized, 

137 
thickening  of,  simulates  enlarged 

heart,  209 
tumors  of,  cyanosis  an   effect  of, 
44 
Medicines,  exanthem  from  use  of,  50 

urine  as  affected  by,  450 
Medulla,  anaemic  necrosis  of,  462 
blood-supply  of  462 
softening  of,  599 


Melaena  neonatorum,  hemorrhage  of 

stomach  with,  362 
Melanaemia    defined,  and  connection 

with  malaria,  280 
Melancholia  attonita,  536 
Melanotic  tumors,  color  of  urine  with, 

411 
Meltzer,  reference  to,  297 
Meniere's    disease,    tinnitus    aurium 

with,  573 
Meninges,  disease  of,  feeling  of  con- 
striction about  thorax  in,  482 
tumors   of,   disturbances  of  con- 
sciousness from,  471 
Meningitis,  anosmia  from,  573 

basilar,  rigidity  of  neck  in,  468 

slow  pulse  in,  237 
breathing  in,  91 
cerebro-spinal,  herpes  with,  50 
irregular     temperature 
with,  71 
Cheyne-Stokes  respiration  in,  92 
choked  disc  with,  600 
consciousness  may  be  retained  in. 

471 
disturbance  of  consciousness   in, 

470 
drawing-in  of  abdominal  wall  in, 

309 
from  disease  of  the  nose,  576 
headache  with,  482 
irregular  temperature  in,  71 
neuro-retinitis  with,  601 
pain  in  spine  in,  483 
posture  in,  33 
pulse  in,  245 

purulent,    affections   of   hearing 
with,  572 
relation  of,  to  disease  of  the 
lungs,  576 
sensibility  of  cranium  to  pressure 

in,  466 
slow  pulse  with,  239 
spinalis,  herpes  zoster  in,  581 
spinal,  rigidity  of  spinal  column 

in,  468 
tenderness  of  vertebrae  in,  467 
tubercular,    suspected  when   nu- 
trition is  poor,  575 
value  of  pulse  in  showing  devel- 
opment of,  253 
vomiting  in,  358 
Memory,  loss  of,  556 

testing  of,  469 
Mental  condition,  during  spasm,  530 
disease,  first  traces  of,  470 


42 


658 


INDEX. 


Mental  diseases,  hemidrosis  in,  38 
disturbance  due  to  fever,  60 
impressions     produce     perspira- 
tion, 36 
nerve  illustrated,  485 
Mercurial  poisoning,  21 

cause  of  paleness,  41 
Mercury,  cocci  in  mouth  in  poisoning 
by.  289 
condition   of  teeth   in  poisoning 

by,  286 
headache  in  poisoning  with,  483 
neuralgia  from    poisoning   with, 

483 
salivation  caused  by,  289 
Mesenteric  glands,  disease  of,  forms  of 

fat  found  in  feces,  in,  386 
Mesocardia,  211 
Mesogustrium  defined,  297 
Metallic  aiter-sounds  defined,  112 
associated     sound     accompanies 

bronchial  breathing,  148 
heart-sound,  210 
murmurs,  227 
pericardial  splashing,  233 
poisons  from  inhalation,  21 
rales,  ir)0 
sound  defined,  112 

with  pneumothorax,  135 
with  various  conditions,  136 
tone     over    large    cavities    with 
smooth  walls,  131 
Metamorphosing    breathing   defined, 

148 
Meteorism  cause  of  diminished  area 
of  liver-dulness,  331 
effect  on  extent  of  abdomen,  309 

on  form  of  chest,  86 
employment  of    deep   breathing 

in,  323 
intestinal,  313 

or  peritoneal,  metallic  heart- 
sounds  with,  221 
pressure    by,    upon     liver,     dia- 
phragm, lungs,  heart,  309 
with  and  without  pain,  value  of, 
in  diagnosis,  314 
Meteorismus  peritonei  defined,  313 
value  of  percussion  in,  317 
Methsemoglobin,  absorption  band  of, 
273 
in   the   blood    in    poisoning    by 

chloride  of  calcium,  272 
spectroscopic  examination  for,  442 
Methods  of  auscultation,  direct  and 
indirect,  138 


Methods  of  percussion  of  thorax,  118 
Methyl-violet  test  for  free  muriatic 

acid,  451 
Miasm,  21 
Microcephalus,  465 
Micrococci,    casts   of,   in   septic   pro- 
cesses, 427 
in  mouth,  289 

in  purulent  plural  exudation,  161 
in  sputum  from  mouth,  188 
Micrococcus    gonorrhoeus    described, 
604 
tetragenus,  184 
ureae,  426 
Micro-millimetre,  value  of,  185,  note. 
Micron,  a  measure,  value  of,  185,  note. 
Microorganisms,  examining  blood  for, 
273 
in  mouth,  289 
in  sputum,  167 

in   stomach,   destroyed    by   anti- 
septic    action    of    gastric 
juice,  343 
excess  of,  345 
in  the  blood,  280 
in  urine,  staining  of,  415 
mode  of  examining  blood  for,  282 
that  excite  fermentation,  342 
Microcytes,  276 

in  anaemia,  276 
in  pernicious  ansemia,  276 
Microcythaemia,  274 

after  hemorrhages  in  anaemia,  276 
Microscope,  diagnosis  of  thrush  by  aid 
of,  288 
examination  of  contents  of  mouth 

by,  289 
generally  useless  in  determining 

hemorrhage  of  stomach,  365 
magnifying  power,  use  in  exam- 
ining the  blood,  273 
use  of,  in  diagnosis  of  diseases  of 
palate  and  pharynx,  291 
in  examining   for  cocci  and 
bacilli  in  urine,  426 
urinary    sediments,  415, 
419 
in  haematuria,  value  of,  418 
Microscopic  appearance  of  uric  acid, 
428 
examination    of  blood,  mode   of 
procedure,  273 
value  of,  271 
of  urate  of  soda  and  lime,  429 
Micturition,  difficult,  a  cause  of  dimi- 
nution in  amount  of  urine,  407 


INDEX. 


659 


Middle  cranial  fossa,  effect  of  lesion 

of,  457 
Migraine   defined,  symptoms  of,  and 
when  occurs,  483 
hemidrosis  in,  38 
inequality  of  the  pupils  in,  567 
sometimes    preceded   by  tinnitus 

aurium,  573 
temporary  partial   amaurosis  in, 

571 
unilateral  redness  of  head  in.  577 
vomiting  with  attacks  of,  578 
Miliaria.  50 

Miliary  tuberculosis  affecting  the  cho- 
roid, 562 
Milk,  color  of  stool  wlien  the  diet  con- 
sists of,  373 
particles  of,  in  sputum,  175 
Miller,  reference  to,  391 
Milliampere-meter,  503 
Mind,  condition  of,  mode  of  examin- 
ing, 469 
Minimal  contraction,  512,  514 
Minkowsky,  reference  to,  449 
Miserere,  when  occurs,  364 
Mitral  disease,    enlargement  of  liver 
with,  322 
of  heart,  paleness  in,  41 
venous  engorgement  in,  261 
first    sound,   the    loudest    heart- 
sound,  217 
insufficiency,  194,  195,  196 

and  stenosis,  effects  of,  195 
color  of  skin  in,  41 
dyspnoea  in,  96 
murmur  of,  224,  225 
pulse  with,  242 
systolic   venous   pulse  with, 
267 
murmur  heard  at  apex,  224 
stenosis,  194 

absence  of  pulse  with,  243 
arhythm  of  pulse  in,  241 
character  of  pulse  with,  243 
division  of  second  sound  at 

apex  in,  220 
double  sound  over  crural  ar- 
tery in,  259 
first  sound   strengthened  at 

apex  in,  218 
pulse  in,  251,  253 
weakening  of  aortic  second 
sound  in,  219 
valve  causes  a  systolic  sound,  213, 
214 
where  best  heard,  213,  214 


Mobility    of   spinal    column    dimin- 
ished, 467 
of  spleen,  335 
Mode  of  life,  effect  on  complexion,  39 
Moist  cough  described,  166 
rales,  149 

explained  ;  when  occur,  151 
Monoplegia,  457 

facialis,    brachialis,   cruralis,  de- 
fined, 489 
with  partial  epilepsy,  533 
Monos  (infusorium)  in  sputum,  183 
Moore's  test  for  sugar,  445 
Morbus  Addisonii,  48 

Basedowii,  apex-beat  with,  201, 
216 
blowing  mnrmur  with,  259* 
tremor  of,  531 
Werlhofii,  hfematuria  in,  417 
Morenheim's  depression  defined,  76 
Morgagni,  sinus,  591 
Moritz,  reference  to,  132 
Morphia,  effect  of,  on  pupil,  567 
induces  perspiration,  37 
poisoning     by,    Cheyne  -  Stokes 

breathing  in,  92 
tremor  from,  531 
Mosso,  reference  to,  93,  note. 
Motility,  disturbances  of,  488 

of  lungs,  when  diminished,  137 
Motion,   loss   of,    from    paralysis   and 
stiffness  not  to  be  confounded,  488 
Motor  aphasia,  553 

cortical  regions,  location  of,  466 
of  occipital  and  temporal 
lobes,  relation  to  cra- 
nium, 465 
cranial  nerves,  455 
memory,  549 
points,  508 
stimuli,  456 
Mould  in  sputum,  190 
Mouth,  effect  of  opening  and  closing 
of,  upon  the  pitch  of  sound.  111 
examination  of,  284 
microscopical  examination  of  con- 
tents of,  289 
odor  from,  importance  of,  285 
open,  tympanitic  sound  when  it  is 
percussed,  110 
Movements,  associated,  defined,  535 

sensation  of,  defined,  474 
Mucin  in  urine,  test  for,  441 
Muco-purulent  sputum  described,  168 
Mucor  (mould)  in  sputum,  190 
Mucous  colic,  374 


660 


INDEX. 


Mucous  corpuscles  in  vomit,  365 
deposits  upon  larynx,  692 
infarction,  mucus  in  feces  in,  387 
membrane  of  larynx,  color  of,  591 

reflexes  of,  496 
sputum  described,  168 
stool  described,  and  sisrnificance 

of,  373 
threads  in  urine  not  to  be  con- 
founded with  casts,  416 
Mucus,  cloud  of,  in  normal  urine,  402 
in  feces,  387 

in  three  layers  described,  169 
in  urine,  416 

causes  it  to  be  jelly-like,  419 
chemical  proof  of,  416 
threads  of,  in  sputum,  175 
Muguet  in  sputum,  175 
Mulberry   tongue    a  sign  of   scarlet 

fever,  287 
Miiller,  reference  to,  386,  387 
Miiller,  F.,  reference  to,  371 
Multiple  neuritis,  diagnosis  from  tabes, 
580 
EaR  with,  524 
neuralgic  pain  in,  484 
sclerosis,  allochiria  in,  478 

atrophy  of  the  optic  nerve  in, 

562,  661 
narrowing  of  field  of  vision 

in,  569 
scanning  speech  in,  548 
tremor  with,  531 
Mumps     (inflammation     of     parotid 

gland),  288 
Muriatic  acid,  excess  of,  in  stomach, 
345 
free,  testing  for,  with  phloro- 
glucin- vanillin, 350 
with  tropaolin  paper, 
350 
when  wanting,  356 
in  stomach,  344 
quantitative  examination,  351 
relation  to  pepsin,  352 
Murmurs,  anaemic,  229 

blowing  over  lymphatic  glands,259 

characters  of,  227 

combination  of  several,  diflFeren- 

tiation  of,  228 
diastolic  and  systolic,  228 
diflFerential     diagnosis     between 

peri-  and  endocardial,  232 
double,  described,  259 
endocardial,  loudness  of,  to  what 
due,  223 


Murmurs  heard  over  veins,  268 
heart,  when  heard,  222 
metallic,  227 
pericardial,  230 
presistolic,  228,  251 
explained,  226 
normal  venous  pulse  with,  263 
systolic  and  diastolic,  226 

subclavian,  259 
that  can  be  felt,  227 
Muscles  and  nerves,  electrical  exami- 
nation of,  501 
mechanical    excitability    of, 
526 
auxiliary,  of  inspiration,  96 

of  respiration,  83,  541 
behavior  of,  when  irritated,  507 
diagram  of  their  innervation,  454 
disturbance  of  nutrition  and  tone 

of,  489 
EaR  with  degenerative  atrophy 

of,  524 
increased  tonus  of  voluntary,  535 
motor  points  of,  508 
nutrition  of,  nervous  influence,  456 
of  arm  and  hand,  importance  of 
a  knowledge  of,  and  their  in- 
nervation, 645 
of  the  eye,  action  of,  and  paralysis 
of,  562 
function  of  individual,  564 
paralysis  of,  562 
of  the  lower  extremity,  646 
of   the    thorax,    diaphragm   and 
abdomen,  640 
effects  of  paralysis  of,  640 
of  the  trunk,  action  of,  and  effect 

of  paralysis  of,  539 
of  the  upper  extremity,  540 
spinal,  pain  in,  483 
tonus  of,  528 

voluntary,  innervation,  function, 
and  the   diseases  that  disturb 
them,  536 
Muscular  atrophy  from  diseased  joints, 
lessened  excitability  with- 
out EaR,  525 
spinal  progressive,  fibrillary 
contractions  in,  532 
dystrophia,  493 

irritation,  direct,  on  the  back,  512 
rheumatism,  pain  in  spinal  mus- 
cles, 483 
sense,  474,  480 
defined,  480 
test  for,  481 


INDEX. 


661 


Muscular  sense,  tract  of,  459 
Musculo-spiral  nerve,  examination  of, 
512 
muscles  supplied  by,  ex- 
amination of,  515 
paralysis  of,  from  com- 
pression, 487 
Music  an  acquired  faculty,  549 

power  to  firoduce,  550 
Mydriasis,  566,  567 
Myelitis,  580 

allochiria  in,  478 

diminished  tendon  reflex  in,  500 

transversa,  492,  493 

clonic  spasms  in,  532 

cystitis  in,  579 

increase  of  tendon  reflex  in, 

500 
involuntary  passage  of  urine 
in,  580 
Myocarditis,    arhythm    of   pulse    in, 
241 

flbrinous,  slow  pulse  in,  237 
pulse  in,  252 

pulsus  intercedens  in,  241 
weak  apex-beat  in,  201 
Myopathic  muscular  atrophy,  EaR  in, 
524 
lessened  excitability  in, 
without  EaR,  525 
paralysis,  EaR  not  present  in,  525 

skin  reflex  lost  in,  496 
progressive  muscular  atrophy,  525 
spasm,  493 
Myopia,  567 
Myosis.  566,  567 

Myositis   ossificans,  a  cause  of  rigid 
thorax,  91 
cyanosis  with,  44 
Myotonia  congenita,  532 

increased  mechanical  excita- 
bility in,  526 
Myotonic  reaction,  described,  524 
in  Thomsen's  disease,  518 


NAILS,  in  peripheral  paralysis,  583 
Names  of  diseases,  misuse  of,  19 
Naphthalin,     color     of    urine    after 

taking,  411,451 
Narcotics,    disturbance  of  conscious- 
ness in  poisoning  by,  470 
Nasal  polypi,  cause  of  neuroses,  575 
Naunyn,  reference  to,  449,  478,  575 
Neck  and  head,  points  of  electrical 
irritation  upon,  illustrated,  508 


Neck,  nerves  of,  485 
Neelsen,  reference  to,  187 
Negative  venous  pulse,  263 
Neisser,  reference  to,  427 
Nelaton's  oesophageal  catheter,  use  of, 
to  wash  out  stomach,  347 
sound,  use  of,  302,  355 
Nephritis  a  cause  of  cardiac   hyper- 
trophy, 196 
of  dropsy,  53 
acute  and  chronic,  albuminuria 
with,  435 
casts  of  albumin  in  urine  of, 

424 
hemorrhagic,     desquamation 
of  renal  epithelium  in,  424 
slow  pulse  with,  237 
amount   of   diminution  of  urine 

indicates  severity  of,  407 
bacteria  in  urine  of,  427 
casts  the  infallible  sign  of,  420 
chloride   of  sodium  in  urine  di- 
minished, 434 
chronic,  cause  of  paleness,  41 
haemorrhagica,     blood-corpuscles 

in  casts  in  urine  of,  423 
mucus  threads  in  urine  of,  beside 

casts,  416 
oedema  with,  54 
parenchymatous,    pus-corpuscles 

in  urine  of,  420 
renal  casts  in  urine  of,  422 

epithelium  in  urine  of,  421 
retinitis  with,  601 
saliva  contains  urea  in,  289 
sequela  of  scarlet  fever,  22 
sometimes    phosphates   in   urine 

are  diminished  in,  435 
sweat  in,  38 
tenderness  in  acute,  not  chronic, 

395 
tracing  of  pulse  of,  247 
turbid  urine  in,  412 
urea  diminished  in,  434 
Nephrolithiasis,  433 

hsematuria  with,  417 
Nerve   centres,  vasomotor  influences 
from,  on  pulse  in  symmetrical 
vessels,  257 
faradic  examination  of,  described, 

512 
lesion   of,   degeneraiive   atrophy 

from,  491 
points,  508 

sensibility  to  pressure  in  neuritis, 
468 


662 


INDEX. 


Nerve  trunk,  exiimination  of,  its  course 

must  be  known,  468 
Nerves  and  muscles,  electrical  exam- 
ination of,  601 
cutaneous,  of  the  lower  extremity 

illustrated,  487 
distribution  of  sensory  cutaneous, 

484 
individual  peculiarities  of  in  re- 
lation to  the  skin,  504 
irritation  and  pain  from  pressure, 

section  on,  482 
mechanical  excitability  of,  526 
neuralgia  as  sequela  of  inflamma- 
tion of,  483 
of  head,  484,  485 
of  lower  extremity,  488 
peripheral,   and   their  surround- 
ings, 468 
points  of  tenderness  in,  484 

of  stimulation,  508 
shoulder,  arm,  and  hand,  485 
Nervous  cough,  a  dry  cough,  166 
during  menstruation,  165 
disease  of  heart,  increases  strength 

of  heart-sounds,  216 
diseases,  diagnostic  value  of  symp- 
toms in,  583 
disturbances  of  the  vegetative 

system  in,  575 
importance  of  scars  from  in- 
juries, 52 
local  sweating  in,  38 
patients,  rapid  breathing  in  fever, 

94 
system,   anatomical    diseases   of, 
586 
anatomy  of,  452 
central,    injuries    to,    glyco- 
suria after,  443 
chapter   on    examination  of, 

452-587 
convulsions  in  disease  of  22 
differential  diagnosis  of  func- 
tional aud  anatomical  dis- 
eases of,  587 
diseases  of,  diagnosis  of,  586 
Nervousness,  dizziness  with,  471 

subjective  sensibility  of  hearing 
in,  572 
Neubauer,  reference  to,  412 
Neukirch,  reference  to,  121 
Neuralgia,  defined,  cause  of,  483 
glycosuria  with,  443 
in  head,  483 
intercostal,  101 


Neuralgia,  sensitive  points  in  nerves, 
468 
simulation  of,  19 
tenderness  of  nerves  during,  484 
with  diabetes  mellitus,  579 
Neuralgic  pain   in    connection  with 
feeling  of  constriction,  482 
in  herpes  zoster,  581 
Neurasthenia,  cerebral,  with  vertigo, 
472 
headache  of,  482 
pain  in  spine  in,  483 
phosphaturia  in,  432 
spinalis,  580 
Neuritis,  acute  degenerative,  493 

acoustic,  subjective  sensibility  of 

hearing  with,  573 
ataxia  in  diffuse  peripheral,  529 
condition  of  nerve  in,  468 
degenerative,  491 
EaR  with,  524 
herpes  zoster  from,  581 
multiple,     lessened      excitability 
v/ithout  EaR  in,  525 
partial  ¥jaR  in,  525 
nerve   sensitive    to    pressure   in, 

484 
of  phrenic    nerve,  effect  on  dia- 
phragm, 90 
optica,  652 

from    intracranial    pressure 
600 
peripheral,  cyanosis  in,  43 

degenerative    atrophy   with, 

491 
gangrene  in,  577 
with  diabetes  mellitus,  579 
Neuro-fibroma,  condition  of  nerve  in, 

468 
Neuroma,  condition  of  nerve  in,  468 
Neuro-retinitis  Brightii,  choked  disk 
with,  601 
diabetic,  602 
when  occurs,  601 
Neuroses,  hypersecretion  of  stomach 
in,  357 
increased  tendon  reflex  in,  500 
joint,  583 

local  sweating  in,  38 
narrowing  of  field  of  vision  in, 

569 
phenomena  of  pulse  in,  577 
pulse  in  certain,  240 
sometimes  inherited,  20 
vomiting  in,  358 
Neurosis,  slow  pulse  as  a,  238 


INDEX. 


663 


Neurotic   bronchial  spasm,  cause  of 
dyspnoea,  94 
causes  for  glycosuria,  443 
Newly-born,  urate  casts  in  urine  of, 
424 
urine  of,  frequently  contains 

albumin,  405 
weight  of,  35 
Nicotine,  headache  in  poisoning  with, 
483 
neuralgia  from  poisoning   with, 

483 
poisoning,  effect  on  heart,  201 
palpitation  of  heart  in,  577 
Niemeyer,  P.,  reference  to,  140 
Night-sweats  in  phthisis,  38 
Nitrate  of  silver,  deposit  of,  49 
Nitric  acid  test  for  albumin,  436 
Nitro-benzole,  color  of  blood  in  poi- 
soning by,  271 
poisoning  by,  odor  of  bitter 
almonds  in  vomit,  366 
Nocturnal  enuresis,  400 
Noise  of  spun-top  described,  134,  135 

where  it  occurs,  134 
Noma,  description  of,  288 
Non-tympanitic  sound  caused  by  ten- 
sion, 111 
defined,  108 
from    closed    air-cavity, 

110 
over  sternum,  121 
transition  to  tympanitic, 

explained,  112 
where  occurs.  111,  112 
Noorden,  reference  to,  404 
Normal  boundaries  of  lungs,  119 

electrode,  502,  503,  506,  507,  512, 

516 
percussion  boundaries  of  lungs, 
121 
Nose,  blood  from,  appears  as  hsemate- 
mesis,  361 
disease  of,  migraine  with,  483 
examination  of,  73 
fluids  escape  by,  in  paralysis  of 

soft.palate,  537 
nerve-supply    of   mucous    mem- 
brane of,  484 
relation  of  diseases  of,  to  nervous 

diseases,  575 
suppuration   of,  cause  of  menin- 
gitis and  abscess  of  brain,  467 
Nostrils,  how  dilated,  536 
Nothnagel,  reference  to,  373,  374,  387, 
388 


Nourishment,  insuffidient,  a  cause  of 

drawing-in  of  abdomen,  309 
Nuclear  paralysis,  synonym  for  bulbar 

paralysis,  497 
Nursling.     Also  see  Children. 
Nurslings,  stomach-digestion  in,  344 
Nutrition,   disturbance  of,   cause    of 
ophthalmia       neuro-para- 
lytica,  484 
disturbed,  blood  coagulates  slower 

in,  283 
how  to  judge  of,  34 
of  muscles,  488,  489 
signs  of,  489 

variously   affected  in  diseases  of 
the  nervous  system,  575 
Nylander's  reagent,  444 
Nymphomania,  472 
Nystagmus,   horizontal  and  rotatory, 
defined, 565 


0  abbreviation  for  opening  of  cur- 
,     rent,  506 
Obermeier,  reference  to,  281 
Obersteiner,  reference  to,  478 
Oblongata,  455,  461 

diseases  of,  glycosuria  in,  443 
effect  of  lesion  of,  457 
glycosuria  in  disease  of,  579 
Obstipation  (constipation),  369 

increase  of  indican   in  urine  in 

obstinate,  409 
large  stools  after  prolonged,  370 
Obturator  nerve,  illustrated,  487 
Occipital  lobe,  blood  supply  of,  462 

centre  for  conception  of  writ- 
ing in  optic  portion  of  cor- 
tex of  the,  555 
illustrated,  466 
lobes,  effect  on  vision  of  lesion  of, 

460 
nerves  illustrated,  485 
Occupation  a  cause  of  disease,  21 
Oculomotorius,  absence  of  pupillary 
reaction    of  light  in  paralysis 
of,  568 
inequality  of  pupils  in  unilateral 

paralysis  of,  567 
muscle,    dilatation    of    pupil    in 

paralysis  of,  566 
total  paralysis  of,  565 
Odor    from    mouth,    importance    of, 
285 
of  expectoration,  168 
of  sputum  described,  171 


664 


INDEX. 


Odor  of  urine,  pathological,  414 
Odors  of  urine,  normal   and  adven- 
titious, 404 
CEdema..  52 

a  result  of  general  venous  engorge- 
ment, 261 
cause  of,  explained,  54 
collateral,  54 

deceptive  increase  of  weight,  35 
distinguished  from  emphysema  of 

skin,  55 
due  to  ankylostomo-anaemia,  5i 
from  kidney  disease,  440 

nephritis,  54 
in  paralysis,  577 
may  conceal  venous  stasis,  262 
near  heart,    weakens   apex-beat, 

201 
of  chest- wall,  cause  of  deadened 
sound,  130 
weakened  vocal  fremitus 
with,  158 
of  engorgement,   venous  throm- 
bosis with,  268 
of  glottis,  cause  of  cyanosis,  43 
of  larynx,  594 
of  legs,  from  compression  of  iliac 

veins,  314 
of  lungs,  albumin  in  sputum  in, 
190 
bloody  sputum  with,  170 
crepitant  rales  with,  154 
dyspnoea  in,  95 
serous  sputum  a  peculiarity 

of,  169 
tympanitic  sound  with.  111, 
130 
showing  deep  abscess,  54 
slight,  disappears  between  even- 
ing and  morning,  54 
striae  from,  52 
(Edematous  skin  in  empyema,  86 
Q5sophagoscopy,  297 
CEsophagus,  anatomy  of,  291,  292 
auscultation  of,  297 
carcinoma  of,  producing  pressure- 
paralysis  of  recurrent  nerve,  638 
compression  of,  296 
congenital  stenosis  of,  292,  296 
danger  of  inducing  emesis  when 

it  is  eroded,  342 
dilatation  of,  296 
disease  of,  a  cause  of  drawing-in 

of  abdomen,  309 
examination  of  neighborhood  of, 
291,  296 


QEsophagus,   expectoration    from,   in 
hysteria,  171 
location  of  stricture  of,  295 
obstruction  of,  296 
percussion  of,  296 
perforation  of,  cause  of  pneumo- 
thorax, 210 
pressure    upon    recurrent  nerve 

from  carcinoma  of,  255,  599 
recurrent  paralysis  a  symptom  of 

carcinoma  of,  600 
rupture  of,  a  cause  of  emphysema 

of  skin,  56 
sounding  of,  dangers  of,  294 
difficulties  of,  294 
method  of,  293 
stenosis  of,  obstipation  with,  369- 
Oidium  albicans,  description  of,  287 
Old  age,  anosmia  in,  573 

nutrition  of  skin  in,  36 
reaction  of  pupils   to  light, 

slow  in,  567 
slow  pulse  in,  237 
Olfactory  nerve,  461 

anosmia  with  compression  of,. 
573 
Oligocythsemia,  diminution  of  red  cor- 
puscles, 273 
haemoglobin  diminished  in,  275 
occurs  in  ansemia,  274 
Oliguria  in  hysteria,  579 
Omentum,  dulness  over,  from  fat,  30& 
examination  of,  340 
shrinking  of,  in  tuberculosis,  340- 
Onanism  concealed,  20 
One-sided  action  of  diaphragm,  90 
Open      pneumothorax,      tympanitic 

sound,  110,  111,  113 
Ophthalmia,  neuro-paralytic,  484 
Ophthalmic  artery,  461 
Ophthalmoplegia  externa,  566 
Ophthalmoscope,    examination   with^ 

600 
Opisthotonus,  496,  532,  534,  539 
defined,  468 

with  meningitis  and  tetanus,  467 
Opium    poisoning,    Cheyne- Stokes 

breathing  in,  92 
Optic  nerve,  551 

absence  of  pupillary  reaction 

in  atrophy  of,  568 
atrophy  of,  after  severe  hem- 
orrhages, 602 
in  diabetes,  602 
in  tabes,  562 
course  of,  460 


INDEX. 


665 


Optic  nerve,   dilatation   of  pupil  in 
atrophy  of,  566 
illustrated,  460 
inequality  of  pupils  in  paral- 
ysis of  the,  567 
lesion  of,  565 
narrowing  of  field  of  vision 

from  atrophy  of,  569 
primary    atrophy    of,   when 
occurs,  601 
thalamus,  454 

blood  supply  of,  4&2 
hemichorea  with  lesion  of,  535 
Organic  heart  murmurs  explained,  221 
Orthopnoea,  97 

diseases  in  which  it  occurs,  32 
effects  of,  33 
in  heart  disease,  197 
Oscillation  of  the  eyeball,  565 
Osier,  reference  to,  282,  391 
Osmic    parsesthesia   in   hysteria   and 

insanity,  574 
Osteomyelitis,  staphylococus  pyogenes 

in,  603 
Ostium  venosum,  218 
Ovarian  hypersesthesia,  581 

tumor,  differential  diagnosis  from 
tumor  of  kidney,  396 
made  out  after  tapping  abdo- 
men, 318 
Oxalate  of  lime,  concretions  of,  433 
in  sputum,  182 
in  urine,  forms  of,  described, 

429,  430 
microscopic    appearance   of, 

430 
wheu  it  occurs,  430 
Oxaluria  defined,  430 
Oxybutyric  acid   interferes  with  cir- 

cumpolarization  for  sugar,  447 
Oxygen,  deficiency  of,  a  cause  of  cy- 
anosis, 43 
diagnostic  importance  of,  270 
effect  of  deficiency  of,  on  color  of 
blood,  270 
Oxyhsemoglobin,  absorption  band  of, 
271,  272,  273 
effect  of,  upon  color  of  blood,  270 
Oxyuris  in  vomit,  364 

vermicularis,  described,  382 
found  in  urine,  425 
illustrated,  381 


P 


A  IN,  a  cause  of  rapid  breathing, 

94 
a  cause  of  suppression  of  cough, 
165 


Pain  accompanies  diseases  of  the  ab- 
dominal cavity,  314 
after  use  of  sound  in  oesophagus, 

significance  of,  294 
cold-  and  heat-,  test  of,  475 
dilatation   of  pupil  with  severe, 

566 
effect  of,  on  reaction  of  pupils, 

567 
frequent  pulse  with  severe,  240 
from  pressure  on  nerves,  482 
in  respiration,  a  cause  of  dimin- 
ished vesicular  breathing,  145 
in  spine,  various  causes  of,  483 
in  swallowing,  significance  of,  in 

diseases  of  oesophagus,  292 
produced  bv  pressure  on  stomach, 

299,  300,  303 
produces  perspiration,  37 
restricting  action  of  diaphragm, 

90 
sensibility  to,  how  tested,  476 
spontaneous,  section  on,  482 
syncope  from,  471 
tenderness  of  spleen,  when  occurs, 

335 
thoracic,   produced   bv  pressure, 

101 
with  movements  of  bowels,  when 

occurs,  370 
Palate,  examination  of,  284 
sense  of  taste  in,  461 
soft,  electrical  irritation  of,  510 
examination  of,  290 
innervation  of,  637 
muscles  of,  536 
Pale  skin.  39 
Paleness  due  to  diminished  hasmoglo- 

bin,  40 
unilateral,   in    hysterical    hemi- 

ansesthesia,  577 
various  causes  of,  40 
Palpation  above   and  below  zygoma, 

what  it  shows,  537 
in  disease  of  peritoneum,  314 
in  examining  throat,  285 
of  arteries,  256 
of  intestine,  308 
of  kidney,  importance  of,  895 
of  liver  described,  266 
how  performed,  323 
value  of,  332 
of  mouth,  288 
of  oesophagus,  292,  293 
of   peritoneum   through   vagina, 

316 
of  pharynx,  290 


666 


INDEX. 


Palpation  of  pulse,   how   performed, 
234 
of  rectum  described,  311 
of  spleen,  334 
of  stomach,  302 
of  thorax,  100 
of  veins,  260 

of  vocal  fremitus  described,  156 
respiratory,  how  performed,  103 
use  of,  in  heart-murmurs,  227 
Palpatory  percussion  of  heart's  resist- 
ance, 205,  208 
Palpitation  in  organic  disease  of  heart, 
677 
nervous,   causes    stronger  heart- 
beat, 201 
of  heart  in  mitral  defects,  240 
Pancreas,  anatomical  relation  of,  299 
cancer  of,  a  cause  of  jaundice,  47 
examination  of,  340 
Pancreatic  juice,  deficiency  of,  371 
Panizza,  reference  to,  177 
Papilloma  of  larynx  described,  596 
Para-ansesthesia  defined,  479 
Paradoxical  contractions  defined,  527 
Parsesthesia  defined,  and  when  occurs, 
482 
osmic,  574 
Paragraphia,  559 

an  aphasic  symptom,  561 
Parallelism     between     atrophy    and 

paralysis,  493 
Paralvses,  kinds  of,  in  which  there  is 

EaR,  524 
Paralysis  aifecting  the  larynx,  75 
agitans,  530,  531 

and  atrophy,  parallelism  be- 
tween, 493 
the  writing  often  good,  561 
associated  movements  in  cerebral, 

spinal,  and  peripheral,  535 
atonic,  characteristic  of,  494 
atrophic,  490 

atrophy  of  inactivity,  a  result  of, 
490 
of  muscles  with,  491 
cerebral,  EaR  not  present  in,  525 
or  spinal,  above  the  anterior 
horn,  characteristic  sign  of, 
494 
contracture  of  muscles  after,  495 
crossed,  illustrated,  453 
degenerative  atrophic,  492,  518 
determined  by  extent  and  location 

of  lesion,  457 
extent  of,  489 


Paralysis  from  pressure,  partial  EaR 
in,  525 
heart  and  vessels  to  be  examined 

when  there  is,  577 
how  produced,  456 
incontinentia  alvi  with,  370 
increased  excitability  in  cerebral, 

spinal,  and  neuritic,  526 
intermitting,  general,  525 
of  arm,  or  one  side  of  body,  with 

albuminuria,  441 
of  brachial  plexus,  cause  of  anaes- 
thesia of  the  region  of  mediari 
nerve,  487 
of  crico -arytenoid  muscles,  dys- 
pnoea from,  75 
of  diaphragm  cause  of  inspiratory 
dyspnoea,  99 
cyanosis  from,  43 
dislocation  of  heart  in,  200 
of  dilators  of  glottis,  cause  of  in- 
spiratory dyspnoea,  99 
of  extensors  of  the  trunk,  effect 

of,  539 
of  extremities,  cause  of,  457 

illustrated,  453 
of  facial  nerve,  effects  of,  536 

tract,  bone  reflex  present  in, 
500 
of  heart,  pulse  in,  240 
of  intestine  in  peritonitis,  369 
of   laryngeal   muscles,   dyspnoea 

from,  93 
of  muscles  concerned  in  cough, 
165 
of  arm,  542 

of  eye,  significance  of,  564 
of  head  and  neck,  539 
of  inspiration,  effects  of,  on 

thorax,  91 
of  mastication,  tongue,  soft 

palate,  and  pharynx,  537 
of  shoulders,  541 
of  speech,  548 
of  the  lower  extremity,  545 
of  pharyngeal  muscles,  effect  of, 

538 
of  phrenic  nerve  shown  by  pal- 
pation, 103 
of  respiratory  muscles,  cyanosis 
from,  43 
dyspnoea  from,  95 
of  soft  palate  described,  537 
of   various    muscles    of   larynx, 

causes  and  results  of,  598 
of  voluntary  muscle  defined,  488 


INDEX. 


667 


Paralysiri,   peripheral,  disturbance  of 
sensation  lags  behind  that 
of  motion  in,  485 
nails  in,  583 
permanent,  illustrated,  522 
phenomena,  method  of  examina- 
tion, 488 
progressive,  imbecility  with  delu- 
sions in,  472 
signs  of,  23 
syncope  in,  471 
radial,  ansesthetic  zone  with,  479 
rheumatic  facial,  491,  520 
section  on,  488 
tremors    of,   distinguished    from 

spasm,  531 
varieties  of,  determined  by  loca- 
tion of  lesion,  456 
with  partial  EaR,  illustrated,  522 
return  of  motility,  illustrated, 
521 
Paralytic  dementia,  character  of  the 
writing  of,  561 
thorax  described,  84 
Paraphasia,  553,  559 

testing  for,  556 
Paraplegia,    inferior    superior,    457, 

489 
Parasites,  animal,  21 

in  sputum,  182 
in  urine,  424 
intestinal,    nervous   disturbances 

in  children  from,  578 
vegetable,  425 

in  feces,  significance  of,  388 
Parasternal  lines,  defined,  76 
Paresis  defined,  488 

of  detrusor  urinse,  in  tabes,  408 

of  muscle  of  eye,  562 

of  muscles  of  speech,  548 

of  quadriceps  muscle,  546 

symptoms  of,  489 

with  ataxia  in  cerebral  disease, 

529 
with  partial  epilepsy,  533 
Parietal  area  of  heart  changed  by  dis- 
location of,  211 
boundaries  of  organs,  116 
lobes  of  brain,  superior  and  infe- 
rior,  blood-supply  of, 
462 
upper   and   lower,  illus- 
trated, 466 
organs  defined,  113 
tumors  of  chest,  feeling  of  resist- 
ance with,  116 


Parosmia    in    hysteria  and   insanity, 

574 
Parotid  gland,  inflammation  of,  288 
Parturient  patients,  perspiration  of, 

38 
Passive  mobility  of  lungs,  125 
Patellar  reflex,  absence  of,  name  for, 
499 
always  present  in  health,  499 
synonyms  defined,  how  tested, 
498 
Pathogenic    fungi,   found    in    urine, 
varieties  of,  427 
section  on,  389 
Pathological  odor  of  urine,  414 
respiratory  sounds,  144 
urine,  section  on,  406-450 
Pathognomonic  sign  of  tricuspid  in- 
sufficiency, 264 
Patient,  position  of,  during  percussion 

of  thorax,  118 
Pectoralis  reflex,  499 
Pectoriloquy,    Laennec's,    described, 

159 
Pediculi,  marks  of,  51 
Pel,  reference  to,  180 
Peliosis  rheumatica  defined,  51 
Pelvis,  muscles  attached  to,  545 
Pemphigus,  581 
Penzoldt,    reference  to,  143,  198,  306, 

354,  436,  445,  450 
Penzoldt's  test  for  bile  in  urine,  442 
Pepsin,  relation  between,  and  muriatic 

acid  in  the  stomach,  344,  345 
Peptone   in    sputum    after  crises    in 
pneumonia,  190 
in  urine,   confounded  with  albu- 
min, 437 
when  occurs,  439 
test  for,  353 
Peptones,  343 

Peptonizing  of  milk  in  stomach,  344 
Peptonuria  distinguished  from   albu- 
minuria, 435 
when  occurs,  439 
Percussion,  comparative,  118,  121 

for    relative   heart -dulness, 
207 
depth  to  which  it  reaches,  113 
difference     between    weak    and 

strong,  107 
different    results  of   strong    and 

weak  over  spleen,  338 
effect  of  feeble,  114 
foundation  of,  106 
general  remarks  upon,  103 


668 


INDEX. 


Percussion,  gentle  and  strong,  illus- 
trated, il5 
hammer,  104,  105,  120  _ 

used  in  ])legaphouia,  159 
use  of,  116 

in    testing    mechanical 
excitability  of  muscles 
and  nerves,  526 
history  and  methods  of,  104 
light,  in  pleuritic  exudation,  127 
metallic  sound  with,  112 
note,  diiference  by  volume  of  tis- 
t^ue,  107 
variations  of,  in  individuals, 
by  age,  region,  and  sex,  120 
of  abdoininal  cavity,  316 
of  heart,  204 

methods  of,  205 
of  intestine,  311 
of  kidnev,  394 
of  liver,  326 

mode  of.  328 
value  of,  332 
of   lungs,    boundaries  upon  the 
back  illustrated,  123 
in  front  illustrated,  122 
of  oesophagus,  296 
of  spleen,  336 
of  thorax  described,  118 
over  thick  covering,  representa- 
tion of,  113 
results  of,  in  aneurism  of  aorta, 

254 
rod-pleximeter  described,  135 
strong,  of  supra-clavicular  fossa, 
130 
when  not  to  be  used,  117 
value  of,  in  locating  deeply 
seated  deposits,  116 
three  methods  of,  105 
topographical,  defined,  and  uses 

of,  116 
value  of,  in  tumors  of  kidney,  397 
Pericardial  exudation,  cause  of  weak- 
ening of  heart  sound,  219 
conceals  apex-beat  in  dorsal 

position,  201,  202 
cyanosis  from,  43,  44 
exudations,  deadened  sound  over 

lung  compressed  by,  127 
friction  sound,  disappearance  of, 

explained,  231,  232.  233 
murmurs,  230 

changes  in,  in  contrast  with 
endocardial,  232 
sounds,  felt,  204 


Pericardial  splashing,  metallic.  233 
Pericarditis  adhesiva,  a  cause  of  sys- 
tolic drawing-in,  204 
diastolic  collapse  of  cervical 

veins  in,  267 
divided  second  sound  in,  220 
pulse  with,  243 
diagnostic  importance  of  pulse  in, 

253 
differential  diagnosis  from  pleu- 
risy and  peritonitis,  233 
downward  displacement  of  liver 

in,  322 
escape  of  fluid  into  oesophagus, 

296 
externa,  cause  of  diminished  mo- 
tility of  lungs,  137 
friction  sounds  with,  156 
exudativa,    causes    projection   of 
chest-wall,  203 
decreased    tension    of   lung 

near,  135 
effects   on  position  of  liver, 

331 
increased  area  of  heart-dul- 

ness  in,  209 
pulse  in,  252 

tympanitic  sound  near,  130 
weak  apex-beat  in,  201 
friction  sounds  with,  231 
position  of  apex-beat  in,  209 
pulse  in,  253 
value  of  pulse  in  diagnosis  of,  253 

of  radial  pulse  in,  202 
venous  engorgement  from,  261 
Pericardium,  diseases  of,  paleness  of 
symptoms  of,  40 
distention  of,  cause  of  expansion 

of  chest,  86 
effusion  into,  33 
fluid  in,  increases  area  of  heart- 

dulness,  209 
tuberculosis   of,   friction    sounds 
with,  232 
Perichondritis,  594 

laryngea,  from  deep  ulcerations, 

596 
of  trachea  and  bronchi,  172 
Perinephritic  abscess,  cause  of  pus  in 

urine,  419 
Perinephritis,  palpation  of,  395 
purulent,  diagnosis  of,  395 
tenderness  with,  395 
Perineuritis,  condition   of  nerve  in, 
468 
nerve  sensitive  to  pressure  in,  484 


INDEX. 


G69 


Periosteal  and  fascial  reflexes,  499 

reflex,  497 
Periostitis,  neuralgia  from,  483 

of  ribs,  pain  with,  101 
Peripheral  irritation,  sensitiveness  to, 
472 
mixed  nerves,  origin  of,  455 
nerves,    disease     of,    diminished 
tendon  reflex  in,  500 
EaR  with  lesion  of,  524 
examination  of,  468. 
nutrition  of,  456 
neuritis,  ataxia  with,  529 
sight,  testing,  569 
Peripleuritis,  cause  of  deadened  sound, 
130 
effect  of,  on  boundary  of  liver, 
329 
Perisplenitis,  cause   of  apparent  en- 
largement of  spleen,  335 
due  to  stenosis  of  intestine,  310 
Peristalsis,  action  of,  in  digestion,  343 
increased,  character  of  stools  with, 
372 
effect  on  character  of  stools, 

368 
of  stomach,  diminished,  348 
Peristaltic  motions  of  stomach,  in  hy- 
pertrophy and  dilatation,  302 
Peritoneal  deposits,  cause  of  apparent 
enlargement  of  spleen,  335 
eff'usion,  a  cause  of  cyanosis,  45 

alkaline  urine  with,  413 
exudation,  diminished  amount  of 

urine  with,  407 
fluid,  encysted,  315 
friction  sound,  233,  318 

sounds  over  spleen,  339 
Peritoneum,  air  in,  a  cause  of  dimin- 
ished area  of  liver  dulness,  331 
bands  in,  found  after  tapping  ab- 
domen, 318 
distention  of  abdomen  in  diseases 

of,  313  _ 
examination  of,  312 
fluid  in,  gives  deadened  sound, 

114 
pain  in  disease  of,  interfere  with 

circulation,  44 
rapid  breathing  in  diseases  of,  94 
sarcoma  and  carcinoma  of,  315 
tenderness  of  liver,  if  involved  in 

carcinoma  of  liver,  324 
value  of  percussion  over  perito- 
neal cavity,  316 
vomiting  in  inflammation  of,  358 


Peritonitis,  acute,  pain  of  severe,  314 
cause  of  cyanosis,  43 
caution  against  talking  in,  159 
Cheyne-Stokes  breathing' witb,  92 
chronic,    diagnostic    points    of, 
315 
little  or  no  pain  with,  314 
diaphragmatic,     interferes     with 
action  of  diaphragm,  90 
simulates  pleuritis,  161 
dislocation  of  heart  with.  200 
effect  on  form  of  thorax,  86 
fecal  vomiting  in  severe,  364 
general,  cause  of  tympanitic  sound 

with,  130 
grass-green  bilious  vomit  in,  361 
indicau  in  urine  of.  409 
local,  shown  by  palpation,  103 
meteorisra  with,  313 
obstipation  an  early  sign  of,  369 
pain  and  tenderness  with,  308 
paralysis  of  diaphragm  in,  90 
pulse  in,  244,  253 
shrinking  of  omentum  in  simple, 

340 
staphylococcus  pyogenes  found  in 

purulent,  603 
subphrenic,  defined,  317 

friction  sound  with,  233 
tenderness  of  liver  with,  324 
time   when  vomiting  occurs   in, 

359 
tuberculous,  surface  of  liver  in, 

325 
tympanites  with,  309 
Perityphlitis,  paljjation   of  abdomen 

with,  310,  315 
Pernicious  anaemia,  41 

case  of,  with  heart  complica- 
tions, 230 
microcytes   and    macrocytes 

in,  276 
poikilocytosis  not  pathogno- 
monic of,  277 
red     corpuscles     diminished 

and  paler  in,  275 
retinal  changes  in,  602 
size  and  form  of  red  corpus- 
cles in,  276 
Peroneus  nerve,  electrical   examina- 
tion of,  511 
illustrated,  487 
-paralysis  defined,  546 
Perspiration,  36.     Also  see  Sweat, 
a  cause  of  subnormal  temperature, 
63 


670 


INDEX. 


Perspiration  alternates  with   amount 
of  urine,  37 
contains  bile  in  jaundice,  46 
insensible,  37 

greater  at  night,  37 
local,  581 
office  of,  37 
relation  of,  to  amount  of  urine, 

401 
sudamina  after  profuse,  50 
varieties  of,  37 
Perverse    sensibility  to    changes    of 

temperature,  478 
Petechiae,  49,  51 
Petrosal  nerve,  superficial,  461 
Pettenkofer's  test  for  bile  in  urine, 

442 
Petters,  reference  to,  414 
Pfluger,  reference  to,  189,  505,  506 
Pharyngomycosis     leptothricia,     de- 
scription, of,  291 
Pharyngeal    muscles,  action    of,  and 
effect  of  paralysis  of,  638 
syphilis,  usually  with  ulceration 
of  larynx,  595 
Pharynx,  anaesthesia  of,  577 
diseased  condition  of,  290 
examination  of,  284 
expectoration  from,  in  hysteria, 

171 
inflammation  near,  cause  of  cy- 
anosis, 43 
irritability  of,  how  overcome,  590 
muscles  of,  536 
reflex  of,  absence  in  hysteria  and 

bulbar  paralysis,  496 
sound  from,  confusing  to  begin- 
ners, 142 
Phase  des  grand  mouvements,  534 
Phenyl-hydracin  test  for  sugar,  444 
Phimosis,  results  of,  580 
Phlegmon  of  larynx,  594 

progressive,    streptococcus    pyo- 
genes in,  603 
Phlegmonous  laryngitis,   illustrated, 

594 
Phi  oroglucin- vanillin  test  for  free  mu- 
riatic acid,  350 
Phonation  described,  157 

in  paralysis  of  soft  palate,  537 
position   of  vocal   cords   during, 
592 
Phosphate  crystals  in  urine  of  cyst- 
itis, 419 
of  lime  illustrated,  430 
in  urine,  402 


Phosphates,  deposit  of,  in  urine,  402 
in  urine,  diminished  in  rhachitis, 
435 
Phosphatic  calculi,  433 
Phosphaturia  defined,  431 

when  occurs,  432 
Phosphoric  acid,  salt  of,  in  urine,  431 
Phosphorus,  acute  poisoning  by,  leu- 
cin  and  tyrosin  in  urine  of,  432 
lipuria  in  poisoning  by,  447 
odor  of  garlic  in  vomit  in  poison- 
ing by,  366 
poisoning,  a  causeof  jaundice,  47 
ecchymosis  in,  51 
odor  of  breath  in,  285 
peptonuria  with,  439 
Phrenic  nerve,  paralysis  of  one,  shown 

by  palpation,  103 
Phthisical  thorax  described,  84 

ulcer  of  larynx,  illustrated,  594 
Phthisis,  absence  of  cough  in,  a  bad 
sign,  165 
accommodation  in,  96 
and  form  of  thorax,  81 
asymmetry  of  breathing  in,  91 
chronic,    extension    of   area   of 

heart-sounds  in,  217 
cyanosis    from    severe   cough  of, 

166 
diminished  apex  of  lungs  in,  137 
dry  cough  in  beginning  of,  166 
friction  sound  with,  156 
fungi  in  cavities  of,  175 
importance  and  value  of  the  ex- 
amination of  stomach  digestion 
in,  356 
inspiratory  pressure   diminished 

in,  164 
lagging  in,  103 
morning  cough  in,  165 
muco-purulent  sputum  in,  169 
neuralgia  in,  483 
night-sweats  of,  37 
orthopnoea  in,  32 
systolic  subclavian  murmurs  with, 

259 
tenderness  with,  101 
undefined  breathing  in  beginning 

of,  149 
vital  capacity  of  lungs  in,  164 
vomiting  in,  358 
Pick,  E.,  reference  to,  357 
Picric  acid,  color  of  urine  after  taking, 
411 
effects    of,    not   to   be    con- 
founded with  jaundice,  45 


INDEX. 


671 


Picric  acid  test  for  albumin,  436 
Pigeon-chest  described,  88 
Pilocarpin,  effect  of,  on  pupil,  567 
Pio  Foa,  pneumonia  diplococcus   of, 

188 
Piorry,  reference  to,  104,  191 
Pitch,  as  affected  by  tension  of  walls, 
110 
change  of,  in  pneumothorax  with 
fluid,  136 
over  lung  cavity,  13] 
differences  of^  107 
of  closed  air  containing  cavities, 

how  determined,  110 
of  lung-sound  depends  on  tension, 

112 
of  open  tympanitic  sound,  111 
of  vesicular  breathing,  142 
Plantar  nerve  illustrated,  487 
Plasmodium  malarise,  282 
Plegaphonia  defined,  159 
Plethora  distinguished  from  abnormal 

redness  of  skin,  41 
Pleura,  diseases  of,  form  of  thorax  in, 
81 
rapid  breathing  in,  94 
with  effusion,  33 
exploratory  puncture  of,  160 
exudation  in  left,  diminishes  the 

half-moon-shaped  space,  307 
inflamed,  a  cause  of  cough,  165 
serous   exudations  of,  whispered 

voice  with,  159 
shrinking  of,   cause  of  displace- 
ment of  heart,  211 
thick,  feeling  of  resistance  with, 

116 
thickened,  and  pleural  exudation, 

how  distinguished,  129 
thickening  of,  deadened  resonance 
with,  129 
diagnosis    of,    by    puncture, 

160 
simulates  enlarged  heart,  209 
tumors    of,    distinguished     from 
pleuritic  exudate,  160 
one-sided  expansion  of  chest 

in,  86 
weakened     vocal     fremitus 
with,  158 
Pleural  cough,  a  dry  cough,  166 
effusions,  80 

deadened  sound  over,  114 
endothelium  in  exudation,  161 
exudation,  effect  on  boundary  of 
liver,  329 


Pleural  exudation,  effect  of,  on  circula- 
tion through  lungs,  44 
encapsulated,  128 
measurement  of  thorax    in, 
163 
exudations,  a  cause  of  diminished 

vesicular  breathing,  145 
inflammations    restricting  the  ac- 
tion of  diaphragm,  90 
sacs,  boundaries  of,  80 
surface,  growths  on,  conductors  of 
vocal  fremitus,  158 
Pleurisy,  also  see  Pleuritis,  asymmetry 
of  breathing  in,  91 
caused  by  caries  of  rib,  102 
differential   diagnosis    from  peri- 
carditis and  i)eritonitis,  233 
downward  displacement  of  liver 

in.  322 
due  to  fracture  of  rib,  102 
effect  on  position  of  liver  whether 

on  right  or  left  side,  331 
effects  of,  on  the  chest,  87 
encapsulated,  defined,  129 
exploratory  puncture  in,  162 
exudative,  complicating  pneumo- 
nia, character  of  bronchial 
breathing  with,  147 
non-tympanitic  sound  with, 
112 
first  symptom  of,  137 
lagging  in,  103 
paleness  a  symptom  of,  40 
position  in  bed  in,  32 
shrinking   after,  diminishes  area 

of  spleen  dulness,  339 
tubercular,  161 

with  exudation,  dyspnoea  in,  95 
with  oedema  of  chest-wall,  54 
Pleuritic  eflfusion,  alkaline  urine  with, 
413 
exudation  a  cause  of  displacement 
of  heart,  211 
conceals  apex-beat,  201 
cyanosis  from,  43 
deadened    sound   over    lung 

compressed  by,  127 
deadness  and  feeling  of  re- 
sistance with,  126 
diminished  amount  of  urine 

with,  407 
displacement  of  liver  by,  324 
expansion  of  chest  with,  85 
pulse  with,  245 
vocal     fremitus     increased 
above,  158 


672 


INDEX. 


Pleuritic  exudation,  with  compression 
of  lungs,  bronchial  breathing 
from,  147 
exudations,  segophony  with,  159 
encapsulated,  86 
feeling  of  resistance  with,  116 
with  tumors  of  thorax,  129 
friction-sound,  an   extra-pericar- 
dial,  233 
■  sometimes    heard   when 
there  is  no  inflamma- 
tion, 155 
-sounds  described,  155 

not  to  be  confounded  with 

liumming  rales,  150 
where     most     distinctly 
heard,  155 
Pleuritis,  also  see  Pleurisy,  adhesive, 
vital  capacity  of  lungs  in,  164 
carcinomatous,  161 
diagnosis   by   exploratory   punc- 
ture, 160 
diaphrngmatica  shown  by  palpa- 
tion, 103 
differeiitial  diagnosis  from  pneu- 
monia, puncture  in,  160 
exudative,  displacement  of  apex- 
beat  in,  199 
effect  on  liver-dulness,  330 
fixation  of  heart  in,  200 
inspiratory    pressure    dimin- 
ished in,  164 
tympanitic  sound  with,  111 
weak    bronchial    breathing 
with,  147 
pulse  in,  253 
purulent,  102 
rupture  of  fluid  into  oesophagus, 

296 
septic,  161 
sicca,  155 

friction-sound  with,  156 
tenderness  due  to,  101 
with  emphysema,  friction-sounds 
with,  156 
Pleximeter  defined,  104 
double,  of  Seitz,  105 
finger  used  as,  in  percussing  in- 
testine, 312 
hand  as,  how  to  be  held,  119 
-rod,  described,  135 
use  in  diagnosing  venous  pulse, 

266 
used  in  plegaphonia,  159 
Pneumatometer,  Waldenburg's,  164 
Pneumatometry  described,  164 


Pneumonia,  absence  of  cough  a  bad 
sign,  165 
acute  and  chronic,  alveolar  epi- 
thelium in  sputum  of,  177 
and    pleurisy,    differential   diag- 
nosis when  in  left  chest,  307 
asymmetry  of  breathing  in,  91 
bloody  sputum  of,  169 
bronchial  breathing  in,  146 
caused  by  dust,  21 
chlorides  in  urine  in,  434 
coccus  of,  188 

staining  of,  188 
course  of  temperature  in,  67 
critical  sweat  of,  37 
croupous,  bloody  sputum  in,  170 
crepitant  rales  in,  1-54 
deadened  resonance  with,  126 
fever  in,  65 
fibrinous  tubes  in  sputum  of, 

172 
loud     bronchial      breathing 

with,  147 
tenderness  with,  101 
tough  expectoration  with,  166 
tympanitic  sound  in  stage  of 
engorgement   and 
resolution,  130 
with,  111 
Curschmann's  sj)irals   sometimes 

in  sputum  of,  180 
decided    increase    of   urea   after 

crisis  of,  434 
deglutition,  600 

differential   diagnosis  from  pleu- 
risy, puncture  in,  160 
dyspnoea  in,  95 

effect  on  boundary  of  liver,  329 
extension  of  area  of  heart-sounds 

in.  217 
■fibrinous    tubes    in    sputum   of 

croupous,  172 
friction-sounds  with,  155 
hsemato-jaundice  in,  47 
herpes  facialis  with,  50 
increase  of  urea  in,  433 
increased  vocal  fremitus  with,  158 
lobar,  extent  of  deadening  corre- 
sponds with  lobe  of  lung  in,  126 
lobular,   thickening  and  deaden- 
ing with,  127 
lagging  ill,  103 
massive,  deadness  and  feeling  of 

resistance  with,  116, 126 
non-tympanitic  sound  from  sur- 
rounding tissues,  112 


INDEX. 


673 


Pneumonia  of  left  lower  lobe,  dimin- 
ished   half-moon- 
shaped  space,  307 
extension   of  dead- 
ness  in,  127 
peptone  in  sputum  of,  after  crisis, 

190 
peptonuria  with,  439 
position  in  bed  in,  32 
pulse  in,  239 
rapid  breathing  with,  94' 
reactive  friction  sounds  with,  156 
recurrence  of,  22 
ringing  rales  with,  151 
sometimes  non-ringing  rales  with, 

153 
spirals  in  sputum  of,  173,  175 
undefined  breathing  in,  149 
unilateral   elevation  of  tempera- 
ture in,  71 
ushered  in  by  epileptiform  spasm, 

533 
vomit  in,  358 

with    jaundice,   bile-pigment  in 
sputum  of,  172 
Pneumonic  deposits,  catarrhal,  tym- 
panitic sound  over,  130 
noise  of  spun-top  over,  135 
thickening,  weak  percussion  over, 
115 
Pneumono-koniosis  [disease  from  in- 
halation of  dust],  155 
Pneumo-pericardium,   closed  tympa- 
nitic   sound    heard    over, 
111 
diminished  area  of  heart-dul- 

ness  with,  210 
metallic  heart-sounds  in,  221 
sounds  over,  112 
Pneumo  thoracic     cavity,    rod-plexi- 

raeter  percussion  over,  136 
Pneumothorax,  circumscribed,  86 
complicated  by  effusion  in  pleu- 
ral cavity,  129 
cyanosis  from,  43 
diminished  vocal   fremitus  with, 

explained,  158 
displacement  of  the  apex-beat  in, 

199 
downward  displacement  of  liver 

with,  322,  331 
dyspnoea  in,  95 
effect  of,  on  relative  liver-dulness, 

332 
effect  on  position  of  liver,  whether 
on  right  or  left  side,  331 


Pneumothorax,   effect    of,    on   upper 
boundary  of  liver,  330 
expansion  of  chest  in,  85 
hydro-,   diagnosis  by  exploratory 

puncture,  160 
lung-sound  over,  113 
metallic  heart-sounds  in,  221 
rales  with,  153 
sounds  over,  112,  135 
non  tympanitic  sound  with,  135 
of  right  side  displaces  mediasti- 
num, 137 
one-sided  expansion  of  lung  with, 

136 
open  and  closed  amphoric  breath- 
ing with,  148 
bronchial  breathing  over,  147 
tympanitic  sound  with.  111, 

135 
water-whistling  sound  with, 
153 
plegaphouia  over,  159 
position  in  bed  in,  32 
pulse  with,  245 
sero-  and  pyo-,  succussion  with, 

156 
tympanitic  sound  with,  134 
with  fluid,  change  of  pitch  in,  136 
with  op  en  fistula,  noise  of  spun-top 
over,  134 
Poikilocytes  defined,  277 
Poikilocythaemia,  274 
Poikilocytosis  defined,  277 
in  leukaemia,  279 
not  pathognomonic  of  pernicious 
anaemia,  277 
Poikilo-microcythsemia,  275 
Points  douloureux,  484 
Points  of  electrical  irritation  upon  the 
upper  part  of  the  ihigh  illus- 
trated, 511 
Poisoning  a  cause  of  collapse,  40 

acute,    disturbance  of  conscious- 
ness in,  470 
albuminuria  in  acute,  435 
animal,  petechise,  in,  50 
by  atropine,  red  skin  in,  41 
by  carbonic  acid  gas,  absence  of 
cough  in,  165 
weakn  ess  of  heart-sounds 
in,  218 
oxide,    absorption -bands   in 
blood  in,  272 
by  copper,  286 
by  inhalation,  21 
by  lead,  286 


43 


674 


INDEX. 


Poisoning,  by  mercury  and  lead,  cause 
of  paleness,  41 
cocci  in  mouth  in,  289 
condition  of  teeth  in,  286 
by  nicotine,  effect  on  heart,  201 
by  opium  or  morphine,  Cheyne- 

Stokes  breathing  in,  92 
color  of  skin  in  cases  of,  by  va- 
rious substances,  271 
condition  of  mucous  membrane 

of  mouth  from,  288 
lead,   double    sound  heard  over 

crural  artery  in,  259 
odor  of  breath  in,  value  of,  285 
with  carbonic  acid,  effect  on  color 
of  blood,  270 
Poisons  causing  haemato  jaundice,  47 
corrosive,  hemorrhage  of  stomach 

from  action  of,  362 
effect  of,  upon  the  pupil,  567 
exanthemata  from,  50 
Polarizing    method   for    quantitative 

determination  of  albumin,  438 
Poles  of  battery,  how  to  distinguish 

quickly,  504 
Polioencephalitis,  choreic  motions  in 

paralyzed  limbs,  535 
Poliomyelitis,  491,  493,  580 

acuta,  chronica,  EaR  with,  524 
ushered   in   by   epileptiform 
spasm,  533 
anterior,  chronic,  520 
arrest  of  growth  of  bone  in,  583 
diminished  tendon  reflex  in,  500 
Pollution  from  phimosis,  580 
Polysesthesia  defined,  478 
Polydipsia,  polyuria  with,  406 

to  make  up  loss  of  water,  407 
Polyuria  (diabetes  insipidus),  579 
in  hysteria,  579 
when  occurs,  406 
Pons,  454 

anaemic    necrosis   of,    cause    of, 

462 
ataxia  in  lesions  of,  529 
blood  supply  of,  462 
effect  of  lesion  of,  457 
lesion  in,  effect  of,  456 
motor  cranial  nerves  separate  in, 
455 
Portal  engorgement,   hemorrhage   of 
stomach  in,  362 
vein,   enlargement  of  spleen   in 
occlusion  of  335 
obstruction    of,   a    cause    of 
ascites,  314 


Portal  vein,  scars  of,  effect  on  consist- 
ence of  liver,  326 
Position,  dorsal,  atalectatic  crepitation 
in,  154 
effect  of  change  of,  on  pericardial 

friction  sounds,  232 
of  body,  effect  on  pulse  in,  235 
in  examining  kidney,  395 
of  patient,  31 

during  inspection,  81 

percussion  of  thorax,  118 
effect  on  heart-sounds,  220 
upon  area  of  dulness  in 
hydropericardium,  209 
in  auscultation  of  heart,  211 
in  examining  heart,  206 
variations  of  lung  border   with 
change  of,  125 
Positive  venous  pulse,  systolic,  264 

tracing  of,  265 
Posner,  reference  to,  405 
Posterior  cranial  fossa,  effect  of  lesion 
of,  457 
cutaneous  nerve  illustrated,  487 
roots  of  spinal  nerves,  455 
Posture,  change  of,  effect  of,  on  apex- 
beat,  198 
effect  of,  on  area  of  dulness  in 

exudation,  128 
in  examining  spleen,  336 
Potassium,    iodide     of    urine    after 
taking,  450 
use  of  in  testing  rapidity  of 
passage  of  food  from   the 
stomach,  354 
Poupart's  ligament,  297 
Predisposing    causes,    effects    of,   on 
chronic  diseases,  21 
of  disease,  21 
Pregnancy,  double  sound  heard  ever 
crural  artery  in,  259 
scars  of,  52 
Pressure,  intra-abdominal,  upon  liver, 
319 
intra-cranial,  polyuria  and  gly- 
cosuria with,  579 
on  head  and  vertebra,  pain  from, 

484 
partial  EaR  in  paralysis  from,  525 
sensation  of,  474 
sensibility  of  cranium  to,  466 
-sound  over  large  arteries,  258 
-tone  over  large  arteries,  258 
Presystolic  murmur,  228,  251 
murmurs,  explained.  226 
normal  venous  pulse  in,  263 


INDEX. 


675 


Previous  history,  what  it  comprises,  20 
Primary  myopathic  atrophy,  a  disease 

of  muscle,  493 
Prior,  reference  to,  390,  607 
Profession,  a  cause  of  disease,  21 
Progressive    muscular  atrophy,   491, 
493 
cyanosis  in,  44 
spinal,  EaR  with,  524 
partial  EaR  in,  525 
nuclear  paralysis,  566 
paralysis,  contracted  pupil  with, 
566 
diminution    of   temperature 

with,  575 
fever  with,  575 
mal  perforant,  582 
mydriasis  in,  566 
reflex   rigidity  of  pupil  not  fre- 
quent in,  567 
Propeptone,  rare  in  urine,  439 

test  for,  353 
Prussia  acid  poisoning,  odor  of  breath 

in,  285 
Pseudo-bulbar  paralysis,  548 
-crisis  of  fever,  67 
-hypertrophy,  493 
of  muscles,  490 

how  recognized,  494 
-leukaemia,  41 
Psoas  abscess,  pain  in  inguinal  region 

from,  309 
Psychical  condition  of  patient,  31 
disturbances,  585 

of  respiration,  83 
Psycho-motor  tract,  452 
Psychoses,  acetonuria  in,  448 
catalepsy  with  certain,  536 
increased  secretion  of  saliva  in, 
577 
Ptomaines,  connection  between,  and 

cystin,  432 
Ptosis,  563 
Ptyalism,  288 

Puerile  breathing  described,  142 
Puerperal  fever,  peptonuria  with,  439 
patients,  lactose  in  urine  of,  447 
period,  a  cause  of  disease,  22 
pyaemia,  retinal  hemorrhage  in, 
602 
streptococcus    pyogenes    in, 
603 
Pulmonary  artery,  aneurism  of,  255 
heart-sounds,  both   strengthened 

from  shrinking  of  lungs,  218 
hemorrhage  described,  170 


Pulaxonary  insufficiency,  194,  195 

phthisis.     See  Tuberculosis 

semilunar  murmur,  where  heard, 
224 

stenosis,  194 

murmur  of,  where  heard,  225 
weakening     of     pulmonary 
second  sound  in,  219 
Pulsating  affections,   difficult  to   dis- 
tinguish from  apparent  enlarge- 
ment of  heart,  210 

splenic  tumor,  with  aortic  insuf- 
ficiency, 335 
Pulsation,  epigastric,  302 

near  heart  in  empyema,  204 
Pulsations  at  base  of  heart,  203 
Pulse,  absence  of,  243 

affected  by  external  temperature, 
235 
by  position  of  body.  235 

a  measure  of  the  work  of  left  ven- 
tricle, 218 

arterial,  at  the  spleen,  rare,  257 

auscultation  of,  257 

bulbar,   jugular   sound   with,  in 
tricuspid  insufficiency,  268 

capillary,  256 

diagnostic  value  of,  251 

dicrotic,  tracing  of,  247 

different  forms  of,  242 

double    murmur  with  large  and 
quick,  259 

effect  of  sleep  upon,  235 
of  meals  upon,  235 

equal,  236 

felt  later  than  heart  systole,  204 

filiform  trembling,  243 

frequent,  when  occurs,  238 

hard,  not  to  be  confounded  with 
arterial  sclerosis,  244 

importance  of,  in  pericarditis,  209 

increased  frequency  of,  in  fever, 
60 

in  crises,  63 

in  pyaemia,  69 

intermittent,  236,  241 

irregularity  of  volume  of,  241 

its  value  in  febrile  diseases,  253 

method  of  observing,  235 

negative  venous,  267 

of  no  value  in  distinguishing  sys- 
tolic and  diastolic  murmurs,  226 

pathological  frequency  of,  237 

phenomena  of,  in  neuroses,  577 

quality  of,  236,  241 

quickening  of,  in  vomiting,  359 


676 


INDEX. 


Pulse,  radial  examination  of,  234 

felt  between  the  time  of  first 
and  second  sounds  of  heart, 
212 
in  aneurism  of  aorta,  254 
value  of,  in  pericarditis,  202 
in  showing  work  of  heart, 
202 
relation   of,  to  temperature   not 

constant,  61 
rhythm  of,  236 
size  of,  not  shown  by  sphygmo- 

graph,  250 
slow,  in  jaundice,  47 

then  faster,  with  albuminuria, 

441 
when  occurs,  237 
sphygmographic  tracing   of,  ex- 
plained, 246 
symmetry  of  radial,  245 
tracing  of,  with  temperature,  236 
unequal  in  symmetrical   vessels, 

significance  of,  257 
value  of,  in  showing  beginning 

complications,  253 
variation   of  its   frequency   with 

age,  234 
variations   of,    affected    by   sex, 

235 
venous,  described,  263 

differential  diagnosis  of,  266 
want  of  rhythm  of,  241 
wire,  244 
Pulsus  alternans,  202,  243 
bigeminus,  241,  243,  252 

tracing  of,  250 
celer,  253 

tracing  of,  248 
deficiens,  241 
dicrotus,  243,  244 
durus,  244 
incidens,  252 
inequalis,  tracing  of,  250 
intercidens,  243,  244 
intermittens,  241 
magnus,  244 
mollis,  244 
paradoxus,  243,  263 
tardus,  244 

tracing  of,  249,  250 
vacuus,  244 
Pulvinar  of  optic  thalamus,  effect  of 

lesion  of,  on  vision,  460 
Puncture,  explorative,  use  of,  130 
exploratorv,  of  heart,  234 
of  liver,  326 


Puncture,  variations  of  pressure  dur- 
ing, in  subphrenic  and  pleural 
cavities,  317 
Pupillary  reflex,  496 
Pupils  always  dilated  in  dyspnoea,  99 
as  affected  by  poisons,  567 
changes  of,  bQ'o 
contraction  of,  568 

during  accommodation,  diag- 
nostic significance  of,  568 
dilatation  and  contraction  of,  with 

migraine,  483,  563,  566 
hemianopsic  rigidity  of,  571 
inequality  of,  and  conditions  in 

which  it  occurs,  567 
reaction  of,  in  hysterical  spasms, 

534 
reflex  changes  in  size  of,  567 

rigidity  of,  567,  587 
size  of,  affected  by  degree  of  illu- 
mination, 566 
Purpura  hemorrhagica,  51 
Purulent  exudation,  examination  of, 
161 
in  sputum,  167 
sputum  described,  169 
odor  of,  171 
peptone  in.  190 
white  blood-corpuscles  in,  176 
stools,  when  occur,  376 
Pus  in  urine  gives  a  small  amount  of 
albumin,  435 
makes  it  turbid,  412 
when  occurs,  419 
vomiting  of,  364 
Pustule,  malignant,  21 
Pyjemia,  cutaneous  hemorrhage  in,  51 
enlargement  of  spleen  in,  335 
haemato-jaundice  in,  47 
herpes  with,  50 
intermittent  fever  in,  69 
pulse  in,  239 
rash  resembling  scarlet  fever  in> 

50 
retinal  hemorrhages  in,  602 
staphylococcus  pyogenes  in,  603 
streptococcus  pyogenes  in,  603 
sweat  in,  37 
Pyelitis  calculosa,  398,  433 

stoppage  of  one  ureter  by,  400 
Pyelonephritis,  hyaline  casts,  peculiar 

form  with,  423 
Pyloric  stenosis,  348 

a  cause  of  diminished  volume 

of  abdomen,  309 
diagnosis  of,  303 


INDEX. 


677 


Pyloric  stenosis,  effects  of,  345,  346 

obstipation  with,  361) 
Pylorus,  demonstration  that  it   does 
not  close,  302 
in  distention  of  stomach,  301 
position  of,  298,  299 
scars  and  hypertrophy  of,  303 
separation  of  fluid  and  solids  at, 

o-tu 

Pyonephrosis,  lipuria  in,  447 

palpation  of,  395 
Pyo-pneumocardium,  metallic  splash- 
ing with,  233 
Pyramidal  tract,  452,  454,  455,  456, 
492,  500 
above   the  oblongata,  affec- 
tion of,  548 
injury  of,  457 
in  the  spinal  cord,  EaR  not 

present  in  lesion  of,  525 
lateral,  how  found,  455 
lessened  excitabilityin,  with- 
out EaR,  525 
part  in  skin  reflex,  496 
spasms  from  irritation  of,  530 
tonic  spasms  in  lesion  of,  532 
Pyrosis  hydrochlorica,  357 
Pyuria,  due  to  strangulus  gigas,  425 


QUALITATIVE     excitability     of 
nerves  and  muscles,  516,  518 

Quality  of  contractions,  depends  upon 
the  relation  of  the  nerve  to  the 
skin,  504 
of  pulse,  236 
of  sound,  terms  for,  108 
Quantity  of  expectoration,  168 
Quineke.  reference  to,  161,  267,  271, 

277,  575 
Quinsy  (abscess  of  tonsil),  290 

RACHITIS,   diminution   of   phos- 
phates in  urine  in,  435 
Radial  artery,  abnormal  course  of,  242 
nerve,  electrical  examination  pf, 
511 
faradic  examination  of,  512 
illustrated,  486 
muscles  supplied  by,  exami- 
nation of,  515 
paralysis   of,  from   compres- 
sion, 487 
in  axilla,  488 


Radial    nerve,   small  cutaneous   fila- 
ments  to  dorsum  of  fore- 
arm, 485 
pulse,  asymmetry  of,  245 
diagnostic  value  of,  251 
simultaneous   on   two  sides, 

236 
sphygmographic   tracing  of, 
explained,  246 
Railroad  neuroses,  narrowing  of  field 

of  vision  in,  669 
Rales  acquire  a  metallic  tone,  148 
bubbling,  154 
crepitant,  defined,  154 

sign  of  capillary  bronchitis, 
152 
dry,  explained,  149 
elasticity   of  thorax  in  children 

cause  ringing,  153 
humming,  hissing,  whistling,  so- 
norous, sibilant,  149 
loudness  of,  explained,  152 
metallic,  150 

moist,  explained  and  when  occur, 
151 
not  to  be  confounded  with 
friction  sounds,  155 
palpation  of,  100 
removed  by  coughing,  149 
ringing,  in  thickening  of  lungs, 

152 
sounds  are  rarely  to  be  felt,  .155 
the  substances  which  cause,  165 
toneless,  146 
various  sizes,  152 
Reaction  of  degeneration  (EaR),  490, 
491,  492,  493,  518 
complete  and  partial,  519 
course  of,  520 
diagrammatic  representation 

of,  520 
diseases  which  are  excluded 

when  it  is  present,  525 
distinct  symptoms  of,  587 
mixed,  525 
partial,  525 
significance  of   its   absence, 

525 
varieties  of,  523 
when  occurs,  524 
wanting,  525 
variations  of,  403 
of  expectoration,  168 
of  urine,  generally  acid,  403 
quality  of,  with  galvanic  current, 
505 


678 


INDEX. 


Reaumur,  thermometric  scale,  57 
Records  of  cases,  keeping  of,  24 
Recti    muscles,    intestinal    peristal- 
sis seen  when  they  are  separated, 
310 
Rectum,  odor  of  stool  in  ulceration  of, 
372 
pain  at  stool,  in  various  diseases 

of,  370 
palpation  of,  311 
tumors  of,  examination  for,  311 
Rectus    abdominis    muscle,    dulness 

over,  328 
Recurrent  fever,  defined,  70 

enlargement  of  fever  in,  324 
microorganism  of,  found   in 
blood,  281 
nerve,  compression  of,  296 
effects  of  paralysis  of,  538 
paralysis   of,  from  pressure, 

599 
pressure  upon,  255 
paralysis,  results  of,  698 

what  a  symptom  of,  600 
spirals,  281 
Red  blood-corpuscles,  alterations   in 
size  and  form  of,  276 
changes  in  the   number 

and  character  of,  273 
decomposition  of  a  cause 

of  jaundice,  46 
increase  of   chloride  of 
sodium  in  urine  from 
destruction  of,  434 
in  sputum,  176 
nucleated,  279 
number    of   in   a   cubic 
millimetre    of    blood, 
275 
seldom  found  in  vomit, 
_  365 

size  of,  276 

variation  in  number  of, 
271 
Redness,   local,  when    physiological, 

42 
Reflector,  Tiirck's,  for  examining  the 

larynx,  589 
Reflex,  abdominal,  increase  of,  in  in- 
tercostal neuralgia,  496 
unilateral  absence  of,  587 
arc,  constituents  of,  500 
biceps,  499 

-tendon,  498 
bone,  absence  of,  in  bulbar  paral- 
ysis, 500 


Reflex  bone   present  in  paralysis  of 
facial  tract,  500 
changes  in  size  of  pupils,  567 
choking,    absence  of,   in  bulbar 

paralysis,  496 
cough  165 

cremaster,  defined,  495,  496 
fascial,  497,  499 
increased,  496 

manifestations  of  muscles,  488 
may  be  absent,  496 
patellar,  increased  tonus  of  quad- 
riceps disturbs  the,  498 
name  for  absence  of,  499 
synonyms,      defined,      how 

tested,  498 
tendon,    always    present    in 
health,  499 
pectoralis,  499 
periosteal,  497 

pharyngeal,  absence  of,  in  hys- 
teria, 497 
and    bulbar    paral- 
ysis, 496 
pupillary,  496 
rigidity  of  pupils,  567,  587 
skin,  defined,  how  tested,  495 

increased   by  excitability  of 

anterior  horn,  496 
mechanism  of,  496 
sole  of  foot,  495 
spinal  centres,  455 
suppression  of  urine,  408 

from  echinococcus,  425 
tendo-Achillis,  and  foot-phenom- 
enon defined,  how  tested,  sig- 
nificance of,  499 
tendon,  493 

an  attendant  phenomenon  of 

spasm,  494 
diminished  in  spinal  progres- 
sive muscular  atrophv, 
500 
in  tabes   dorsalis   (very 
important),  500 
illustration  of  mechanism  of 

explained,  500 
increase  and  diminution  of, 
goes      parallel      with 
tonus,  500 
of,  in  cerebral  paralysis, 

500 
in  primary  degeneration, 

600 
in  secondary  degenera- 
tion, 500 


INDEX. 


679 


Reflex  tendon,  increase  of,  in  spastic 
spinal  paralysis,  500 
in  spinal  paralysis  from 
disease    of  pyramidal 
tract,  500 
increased  in  hysteria,  500 
in   strychnia  poisoning, 

500 
in  tetanus,  500 
in   the    phenomenon   of 
paradoxical     contrac- 
tions, 527 
mixture  of,  and  direct  mus- 
cular irritation,  501 
of  upper  extremities,  499 
when  diminished  or  lost,  500 
when  increased,  500 
Reflexes,  bone,  500 

cutaneous  and  tendon,   diagram 

of,  497 
predominant  ones  in  arm  and  lesc, 

500 
seat  of  skin  and  tendon,  528 
skin,  not  so  important  an  aid  in 
diagnosis  as  tendon  reflexes,  498 
tendon,  aid  in  diagnosis,  498 
and  skin,  seat  of,  528 
importance  of,  497 
section  on,  495,  497 
Regional  difference  of  thoracic  sounds, 

125 
Relapsing  fever,  critical  sweat  in,  37 
hectic  with,  69 
leucocytosis  in,  278 
Relative  deadness  of  sound,  108 

heart-,  liver-,  spleen-deadness,327 
liver  dulness,  327 

variation  in  location  of,  332 
Relaxed  lung  tissue,  tympanitic  sound 

with,  112,  130 
Remission  of  temperature,  62 
Remittent  fever,  62,  65,  70 

in  other  febrile  diseases,  68 
range  of  temperature  of,  62 
vomiting,  an  early  symptom 
of,  358 
Remittent  typhus  fever,  hectic  with,  69 
Renal  calculi,  398 

accompanied    by   chill    and 
fever,  64 
colic,  vomiting  in,  358 
engorgement,  hsematuria  in,  418 
epithelium  in  urine,  forms  of,  and 

diagnostic  value  of,  421 
sand,  433 
Rennet  ferment,  343 


Rennet-zymogen  test  for,  353 
Residence,  place  of,  cause  of  disease, 

21 
Residual  urine,  causes  of,  408 

not  normal,  408 
Resistance,  electrical,  as  affected  by 
the  angle  of  entrance  of  the 
current,  504 
inversely  proportional  to  cross 

section  of  electrode,  502 
of  skin,  important  point  re- 
garding its  increase,  503 
feeling  of,  109 

over  hepatized  lung,  126 
power  of,  33 

sensation  of,  described,  116 
Resonance,    deadened,   when    devel- 
oped, 126 
Resorcin,    test  for   muriatic   acid   in 
stomach,  351 
urine  after  taking,  451 
Respiration.     Also  see  Breathing, 
anomalies  of,  89 
change  of  sound  in,  113 
effect  of.  on  apex-beat,  198 
forced,  97 

in  dyspnoea,  96 
how  palpated,  103 
increased,  a  cause  of  dyspnoea,  93 
frequency  of,  in  fever,  60,  94 
in  crisis,  63 

in  relation  to  form  of  thorax,  81 
interference  with   during   an  at- 
tack of  epilepsy,  533 
irregular,  83 
larynx  during  quiet,  592 
motions  of,  81 
normal,  81 

described,  82,  141 
quiet,  heart  dulness  in,  206 
relation  of,  to  amount  of  urine,  401 
sighing,  92 
symmetrical,  83 
tumors   of  kidney  do   not  move 

with,  395 
types  of,  83 
Respirations,  number  of,  82 
Respiratory    apparatus,   disturbances 
of,  in  nervous  diseases,  575 
centre,  457 

disturbance  of,   in    Cheyne- 

Stokes  breathing,  93 
irritation  of,  in  fever,  94 
displacement  of  stomach,  303 
motions,  effect  upon    circulation 
in  jugular  veins,  262 


680 


INDEX. 


Respiratory  movements  of  thorax,  pal- 
pation ofj  100 
palpation  of,  102 
muscles,  dyspncea  from  paralysis 

of,  576 
organs,  cough  as  a  sign  of  disease 
of,  165 
disease  of,  perspiration  in,  37 
sound,  metallic,  136 
sounds,  pathological,  144 
Restlessness  from  uraemia,  440 
JEietentio  alvi,  370 

from  paralysis  of  abdominal 
muscles,  578 
Retention  of  urine,  400,  408,  579 
Retina,  electrical  reaction  of,  571 

embolus  of  the  central  artery  of, 
562 
Retinal  apoplexy,  a  forerunner  of  cere- 
bral hemorrhage,  601 
arteries,  pulsation  of,  when  occur, 

602 
artery,  emboli   of  the  central,  a 
forerunner  of  cerebral  embolism, 
601 
Retinitis  in  syphilis  of  the  brain,  562 

syphilitica,  601 
Retraction  of  apex  of  lung  in  tuber- 
culosis of,  127 
of  lung,  increases  area  of  heart 

dulness,  209 
of  lungs,  measurement  of  thorax 
in,  163 
tympanitic  sound  with,  112 
Retro-peritoneal  glands,  enlargement 
of,  340 
confounded   with  aortic 
aneurism,  341 
-pharyngeal  abscess,  290 

a  cause  of  cyanosis,  43 
Reynolds,  reference  to,  448 
Rhachitis,  464 
forms  of,  88 

how   distinguished   from  hydro- 
cephalus, 464 
Rheumatic  facial  paralysis,  491 

disturbance   of   hearing 

with,  572 
partial  EaR  with,  525 
paralysis,  EaR  with,  524 
Rheumatism,  articular,  recurrence  of, 
22 
chronic    articular,    phosphaturia 
in,  432 
pain  in  spine  with,  483 
inherited,  20 


Rheumatism,  intercostal  neuralgia  not 
to  be  confounded  with,  484 
occasionally  slow  pulse  in,  237 
of  chest-muscles,  pain  in,  101 
of  thoracic  muscles,  rapid  breath- 
ing in,  94 
peptonuria  with  acute,  439 
perspiration  of,  38 
sequelae  of,  22 
simulation  of,  19 
Rhonchi,  metallic  sound  with,  136 
sibilant,  M9 
sonorous^ol,  153 
Rhubarb,  color  of  urine  after  taking, 

411,  450 
Rhythm  of  breathing,  anomalies  of,  91 
of  heart-sounds   described,   212, 

213.  220 
of  pulse,  236 

tracing  of,  250 
Ribs,  character  of  in  phthisical  thorax, 
84 
deformity  of,  82 
form  of,  81,  82 
fracture  of,  diagnosis  of,  102 
how  counted,  77 
in  emphysematous  thorax,  83 
markedly  bowed,  deadened  sound 

over,  114 
pain  in  disease  of,  101 
rapid  breathing  in  fracture  of,  94 
sharply  bowed,  causes  deadening 
of  sound  over,  126 
Rice-water  stools  defined,  374 

vomit,  in  Asiatic  cholera,  de- 
scribed, 361 
Richardson,  reference  to,  246 
Riegel,  reference  to,  153, 173, 182,  246, 

250,  264,  265 
Riess,  reference  to,  208 
Rigidity  of  paralysed  muscles,  494 
Rigors,  in  abscess  of  liver,  326 
Risus  sardonicus,  tonic  spasm  of  face, 

532 
Rod-pleximeter  percussion,  317 
described,  135 
metallic  sound  with,  112 
use  of,  306 
Rolando,  fissure  of,  illustrated,  466 
Romberg's  symptom,  480 
Rosenbach's  test  for   bile  in  urine, 

442 
Roseola,  49 

Round   worms,  described  and  symp- 
toms of,  380 
in  vomit,  364 


INDEX. 


681 


S 


abbreviation  for  Schliesuny,  closure 
5    of  current,  506 
Saccharomyces  in  diabetic  urine,  428 
Sahli,  reference  to,  230,  269 
Salicylic  acid,  urine  after  taking,  450 
Saliva,  acidity  of  stomach,  stimulates 
secretion  of  346 
coloring  matter  of  bile  in,  46 
diminished    in   facial    paralysis, 
_    578        ■ 

increased  secretion  of,  when  oc- 
curs, 577 
nerve  presiding  over  secretion  of, 

484 
various  conditions  of,  287 
when  diminished,  289 
Salivary  glands,  examination  of,  288 
Salivation,  description  of,  288 
Salkowski,  reference  to,  172,  181,  434, 

445 
Salol,  broken  up  in  the  intestine,  made 
use  of  to  determine  rapidity  of 
passage  of  food  from  stomach, 
354 
urine  after  taking,  451 
Salzer,  reference  to,  125 
Sanger,  reference  to,  398 
Santonin,  color  of  urine  after  taking, 
411 
effects  of  not  to  be  confounded 
with  jaundice,  45 
Santorini,  cartilage  of,  591,  592 
Sarcina  in  urine  of  alkaline  fermenta- 
tion, 428 
pulmonalis,  in  sputum,  184 
ventriculi  described,  366 
in  vomit,  365 
Sarcoma  of  kidney,  palpation  of,  395 
of  larynx,  597 
of   lung,   deadened  sound   over, 

127 
of  peritoneum,  315 
of  skull-wall,  465 
Satyriasis,  472 

Scale  of  Fleischl's  hsemometer,  272 
Scanning  speech,  548 
Scapula,  paralysis  of  the  muscles  at- 
tached to,  541 
percussion  note  over,  120 
position  of  82 
Scapular  line,  77,  333 
Scarlet  fever,  49 

ecchymosis  in,  51 
enlargement  of  spleen  in,  334 
epileptiform    convulsions  in 
the  beginning  of,  533 


Scarlet  fever,  glycosuria  in,  443 

haemoglobin  in  urine,  411 

mulberry  tongue  in,  287 

recurrence  of,  22 

red  skin  of,  41 

sequelte  of  22 

slow  pulse  in  nephritis  of,  237 

value   of   pulse  in  showing 

complications  of,  253 
vomiting  in,  358 
Scars,  52 

in  larynx,  causes  of,  596 
on  tongue  due  to  syphilis,  288 
Scherwald,  reference  to,  159,  434 
Schizomycetes  in  mouth,  289 
in  vomit,  365 

pathogenic,  section  on,  389 
the  only  microorganism  found  in 
blood,  280 
Schleroderma,   on  thorax,   effects  of, 

91 
Schreiber,  reference  to,  346,  357 
Schulte,  reference  to,  524,  525,  582 
Scintillations  with  migraine,  483 
Sclerosis,  multiple,  allochiria  in,  478 
vertigo  in,  472 
of  arteries,  cause  of  hypertrophy 
of  heart,  196 
Scoliosis,  467 
described,  88 

from  paralysis  of  erector  trunci, 
539 
Scorbutus,  cocci  in  mouth  in,  289 
condition  of  teeth  in,  286 
cutaneous  hemorrhages  in,  51 
hsematuria  in,  417 
peptonuria  with,  439 
Scotoma,   central,  in  alcohol  and  to- 
bacco amblyopia,  569 
Scrofula,  caries  of  petrous  bone  in,  572 
chronic  catarrh  a  sign  of  74 
nutrition  poor  in,  575 
Scrofulosis  indication  of  tuberculosis, 
22 
scars  of,  52 
Scybala,  diagnosis  of,  310 
Sebacic  acid,  odor  of,  in  vomit,  366 

of  stool  in  infantile  diar- 
rhoea, 371   ■ 
Secretion  of  gastric  juice,  threefold 

importance  of  knowledge  of,  342 
Sediment,  kinds  of,  in  urine,  and  sig- 
nificance of  402 
Sediments  in  urine,  in  inflammation 
of  urinary  tract,  419 
urinary,  of  organic  bodies,  416 


682 


INDEX. 


Seelegmiiller,  reference  to,  485,  496 
Seitz,  reference  to,  105,  148 
Self-consciousness  during    attack   of 

spasm,  530 
Semen,  involuntary  discharge  of,  in 

attacks  of  epilepsy,  534 
Semilunar  valves  cause  diastolic  sound, 

218 
Senator,  reference  to,  177,  405 
Senile  dementia,  mixed  aphasia  and 

amnesia  in,  555 
Senna,  color  of  urine  after  taking,  411, 

450 
Sensation  of  movements  defined,  474 
Sense  of  heat  and  cold,  how  tested,  475 
of  pressure,  474 

of  space  defined,  how  tested,  474 
of  touch,  how  tested,  473 
Senses,  organs  of,  561 

special,  centres  and  tracts  of,  460 
Sensibility,  deep,  459,  473 

part  in  coordination,  528 
part  taken  by,  in  recognizing 

the  form  of  bodies,  481 
section  on,  479 
disturbances  of,  section  on,  472 
local  manifestations  of  disturbed, 

478 
of  skin,  473 

use  of,  in  recognizing  form  of 
bodies,  481 
superficial,  part  of,  in  coordina- 
tion, 528 
to  changes   of  temperature  pre- 
vented, 478 
to  pain,  how  tested,  576 

increase  of,  478 
tract  of,  459 
Sensitiveness  of  vertebral  column  to 

pressure,  467 
Sensory  aphasia,  552 

condition  of  the  hearing  must 
be  determined  in,  578 
cutaneous  nerves,  distribution  of, 

484 
tract,  blood-supply  of.  462 
section  on,  459 
Sepsis,  enlargement  of  spleen  in,  335 
rash  resembling  scarlet  fever  in, 

50 
retinal  hemorrhage  in,  562 
Septic  hemorrhage  of  kidney,  hsema- 

turia  with,  417 
Sequelae,  22 

Serous  sputum,  a  peculiarity  of  oedema 
of  the  lungs,  169 


Serous  sputum  described,  169 
Sex,  variations  of  pulse  from,  235 
Sexual  diseases  concealed,  19 
Seyler,  reference  to,  190 
Shaking  spasm,  531 
Shattuck,  reference  to,  282 
Shoemaker's  breast,  cause  of,  89 
Shoulder,  nerves  of,  485 
Shrinking  of  one  side,  86 
Sibilant  rales,  149 
Sibson's  furrow  defined,  76 
Sieveking's  aesthesiometer,  use  of,  474 
Sighing  respiration,  92 
Sight,  place  of,  in  faculty  of  writing, 
550 
tract  of,  460 
Silver,  nitrate  of,  deposit  of,  49 
Simon,  reference  to,  398 
Simulation  of  disease,  19 
Singultus,  defined,  540 
Sinus  of  peritoneal  cavity,  position  of, 
299 
phrenico-costalis,  80 
Situs  inversus  viscerum,  193 

position  of  liver,  331 
Size  of  body,  relation  to  lung  capacitv, 
164 
of  communicating  opening,  effect 
upon  pitch  of  sound,  109 
Skeleton,  deformity  of,  effect  on  chest, 

88 
Skin,  appearance  of,  over  the  abdo- 
men when  latter  is  distended, 
313 
bronze,  48 
color  of,  38 

as  affected  by  state  of  blood, 

271 
characteristic   in    some   dis- 
eases, 41 
cutaneous     hemorrhages    in,    in 

jaundice,  57 
deep  disturbance  of  nutrition  of, 

iti  diabetes  mellitus,  579 
diagnostic  value  of  its  appearance, 

49 
disturbance  of,  section  on  nervous 

relation  of,  581 
effect  of  thickness  of,  on  conduc- 
tive resistance  of,  512 
emphysema  of,  55 

weakens  apex-beat,  201 
examination  of,  39 
glassy,  581 
hemorrhages  of,  51 
in  cases  of  poisoning,  271 


INDEX. 


683 


Skin  inspection  of,   with  reference  to 
condition  of  blood,  270 
nutrition  of,  36 

oedema  of,  in  perinephritis,  395 
cedeinatous,  in  empyema,  86 
of  face,  dropsy  of  kidney  disease 

first  in,  440 
pale,  39 
redness  of,  41 

reflex,  defined,  how  tested,  495 
increased  by  excitability  of 

anterior  horn,  496 
mechanism  of,  496 
seat  of,  528 
reflexes,  not  so  important  aid  in 
diiignosis   as    tendon   reflexes, 
498 
sensibility  in,  part  in  coordina- 
tion, 459,  527 
use  of,  in  recognizing  the  form 
of  bodies,  481 
state  of,  during  a  chill,  62 
various  conditions  of,  36 
Skoda,  fundamental   sentences  from, 
109 
reference  to,  104, 138, 152, 191, 199 
Skull,  asymmetry  of,  form  of,  455 

examination  of,  463 
Sleep,  effect  of,  on  pulse,  235 

paralysis,  543 
Smallpox,  49.     Also  see  Variola, 
cutaneous  hemorrhage  in,  51 
enlargement  of  spleen  in,  335 
infectious  in  utero,  20 
larynx  in,  75 

leucin  and  tyrosin  in  urine  of,  432 
scars  of,  52 
vomiting  in,  358 
Smegma  bacillus,  400 
Smell,  section  on  sense  of,  461 

testing  the  sense  of,  573 
Smothered  sound,  108 
Snellen's  plates  for  testing  vision,  568 
Sodium,  chloride  of,  in  urine,  434 
Softening  of  pons  or  oblongata,  effect 

of,  457 
Sole  of  the  foot,  reflex  of,  how  elicited, 

495 
Sommerbrodt,  reference  to,  246 
Somnolence  defined,  470 

from  uraemia,  440 
Sopor  defined,  470 

Sound,  abnormally  loud  and  deep  per- 
cussion, where  occurs,  135 
Biermer's   change  of,   described, 
136 


Sound,  conditions  that^etermine  the 
quality  of,  109     * 
dissimilarity  of,  on  right  and  left 

sides  of  chest,  121 
Friedreich's    change   of  respira- 
tory, defined,  113 
described,  133 
individual  differences  of,  120 
metallic,  defined,  112 
moist  cracked-pot,  135 
normal,  over  lungs,  trachea,  and 

larynx,  119 
of  falling  drops,  153 
qualities  of,  terms  for,  108 
rectal,  use  of,  311 
regional  differences  of,  120 
Williams's  tracheal  change  of,  121 
Wintrich's  change  of  described, 
111 
explained,  and  when  oc- 
curs, 138 
Sounds,  centre  for  conception  of,  557 
intellectual  perception  of,  552 
qualities  of,  explained,  106 
Space,  conception  of,  test  for,  481 

complementary,  192 
Spasm,  active,  of  paralyzed  muscles, 
494 
of  muscles  of  speech,  548 
of    thoracic    muscles,    dyspnoea 

from,  95 
sensation  of,  of  muscles,  479 
defined,  480 
Spasms.     Also  see  Convulsions, 
defined,  530 

from  intestinal  parasites,  578 
hysterical,  587 
voluntary  muscles,  530 
Spastic  paralysis,  492 

contracture  after,  495 
pseudo-paralysis,  494 
spinal  paralysis,   flexion  of  foot 
with,  535 
increase  of  tendon  reflex 
in,  500 
Special  senses,  centres  and  tracts  of, 

460 
Specific  gravity  of  urine,  diagnostic 
value  of,  413 
how  measured,  403 
if  high,   sugar  probably 

present,  443 
in  disease,  412 
relation  of  color  to,  408 
Spectroscopic  examination  of  blood, 
270 


684 


INDEX. 


Spectroscopic  examination,  value  of, 
271 
urine,    for    methgemoglobin, 
442 
Spectrum    analysis,   quantitative   for 
determining  amount  of  haemoglobin 
in  blood,  272 
Speech,  an  acquired  faculty,  549 

-centre,  motor,  interruption  of, 
558 
location  of,  555 
difficulty  of  in  bilateral  paralysis 

of  the  soft  palate,  538 
disturbances  of,  548,  549 
how  acquired,  549 
in  paralysis  of  soft  palate,  537 
place  of  hearing  in,  550 
right  hemisphere  has  nothing  to 
do  with,  555 
Spheno  palatine  ganglion,  461 

supplies  the  soft  palate, 
537 
Spermatic  nerves,  illustrated,  487 
Spermatorrhoea,  421 
Spermatozoa,     in    urine,     diagnostic 

value  of,  421 
Sphincter    vesicae,  spasm   of,  due   to 

echinococcus,  425 
Sphygmograph,  pathological  forms  of 
pulse  shown  by,  247 
tracing  of  radial  pulse  explained, 
246 
Sphygmomanometer,  use  of,  245 
Spinal  column,  curvature  of,  effects  of, 
87 
diminished  mobility  of,  467 
section  on,  467 
sensitiveness  to  pressure,  467 
cord,  cervical,  diminution  of  tem- 
perature in  injuries  of, 
575 
injury    to,    fever    with, 
575 
difficulty  of  local   examina- 

of,  463 
disease  of,  feeling  of  constric- 
tion about  thorax  in,  482 
diseases  of,  diagnosis  of,  586 
EaR  not  present  in  paralysis 
from    lesion  of  pyramidal 
tract  in,  525 
incontinentia  alvi  in  disease 

of,  370 
increased   irritability  of,  in- 
creased tendon  reflex  with, 
500 


Spinal  cord,  lessened  excitability  in, 
without  EaR,  525 
lumbar,  residual  urine  in  dis- 
eases of,  408 
lympho- sarcoma  of,  hemial- 

bumose  in,  439 
relation  of,  to  spinal  column 

described,  468 
spasm  from  irritation  of  the 
anterior  horns  of,  530 
curvature,  82 

irritation,  pain  in  spine  with,  483 
tenderness  of  vertebrae  with, 
467 
paralysis,  above  the  anterior  horn, 
characteristic  sign  of,  494 
from    disease    of   pyramidal 
tract,    increase   of   tendon 
reflex  in,  500 
spastic,  dorsal  flexion  of  foot 
with,  535 
progressive  muscular  atrophy,  di- 
minished   tendon 
reflex  in,  500 
fibrillary       contrac- 
tions with,  532 
Spine,  pain  in,  various  causes  of,  483 
Spinning-top,  noise  of,  128 
Spirals,      Charcot-Leyden's     crystals 
'upon  and  in,  182 
Curschmann's,  illustrated,  178 

described,  179 
Finkler-Prior's,  390,  607 
in  sputum  of  croupous  pneumonia, 
173 
of  pneumonia,  175 
Spirillum  recurrens  in  hemorrhage  of 

kidney,  427 
Spirochaeta  in  mouth,  188,  289 
Spirometer,  Hutchinson's,  164 
Spirometry  described,  163 
Splashings  in  intestine,  312 
Spleen,  adjacent  to  fundus  of  stomach, 
299 
anatomy  of,  332 
arterial  pulse  at,  rare,  257 
auscultation  of,  339 
boundaries  of,  336 
consistence  of,  335 
-deadness  illustrated,  304,  337 
diseases  in  which  it  is  enlarged,  334 
-dulness,  enlargement  of,  difficul- 
ties in  determining,  339 
enlarged,  causes  projection  of  left 

hypochondrium,  334 
enlargement  of,  diagnosis  of,  339 


INDEX. 


685 


Spleen,  enlargement  of,  due  to  venous 
engorgement,  260 
effect  of,  on  form  of  chest,  86 
from    venous     engorgement, 

261 
makes  the  half-moon-shaped 
space  smaller,  306 
examination  of,  332 
form  aad  surface  of,  335 
infarction   of,  cause  of   enlarge- 
ment, 335 
inspection  of,  334 
-kidney  angle,  393 
leucocytosis  in  inflammation  of, 

270 
location  of  illustrated,  321 
-lung  angle,  338 

defined, 333 
measuring  the,  337 
mobility  of,  335 
palpation  of,  334 
pathological  relations  of,  338 
percussion  of,  336 
portion  that  is  parietal,  333 
position  of,  79 

illustrated,  333 
relation  to  colon,  336 
to  diaphragm,  332 
to  lung,  333 
size  of,  in  various  diseases,  335 
tenderness  of,  diseases  in  which  it 

occurs,  335 
topography  of,  332 
tumor  of,  306 

not  diagnosticated  from  per- 
cussion alone,  338 
wandering,  described,  336 

differential  diagnosis  of,  397 
when  it  can  be  felt,  334 
Splenic  ansemia,  enlargement  of  spleen 

in,  335 
Sponge,  hot,  use  of,  in  testing  sensi- 
bility of  spinal  column,  468 
Sputum,    character     of,   with    refer- 
ence to  certain  brain  diseases, 
576. 
chemical  examination  of,  190 
crystals  in,  174 
defined, 167 
fibrinous  tubes  in,  172 
importance  of  examiningby  naked 

eye,  171  note 
in  three  layers,  fetid,  described, 

174 
microscopical     examination     of, 
175 


Sputum,  muco-purulent,  crystals  in. 
181 
odor  of,  described,  171 
spirals  in,  174 

substances   visible  in,  by  naked 
eye,  171 
Stadelmann,  reference  to,  443,  449 
Staphylococcus  pyogenes,  602 

cultures  of,  603 
Starch  corpuscles  in  sputum,  180 

grains,  in  vomit,  365 
Starches,  changed    into  erythro-  and 
achroo-dextrin,  353 
interference  with  digestion  of,  344 
Stenosis,  auscultatory  sounds  of,  297 
of  air-passage,    inspiratory   pres- 
sure diminished  in,  164 
labored  respiration  in,  93 
of  aorta,  murmur  of,  when  heard, 
224 
pulse  in,  240,  252,  255 
slow  pulse  with,  237 
of  intestine,   indicated  by  band- 
like, flat  scybala,  371 
obstipation  in,  369 
peristalsis  to  beseen  with,  310 
tympanites  with,  309 
of  larynx,  described,  75 

voice  in,  74 
of  left  auriculo-ventricular  open- 
ing, dyspnoea  in,  96 
of  oesophagus,  292 
of  trachea,  97,  98 
of  upper  air-passages,  cause  of  di- 
diminished  vesic- 
ular breathing,145 
diminished  frequency 
of  respiration  in,  91 
of  valves  and  effects  of,  194 
weaken  the  sounds  of,  219 
Stereognosis,  defined,  and  test  for,  481 
Sterility,  21 

due  to  syphilis,  21 
Sternal  lines  defined,  76 
Sternum,  acts  as  a  thick  pleximeter, 
121 
and  ribs  in  emphysema,  83 
character     of    percussion  -  sound 

over,  123,  124 
heart-sounds  heard  over,  214 
non-tympanitic  sound  over,  121 
Stethography  defined,  164 

of  thorax,  162 
Stethoscope,    double     murmur    from 
pressure  with,  259 
in  examining  heart,  220 


686 


INDEX. 


Stethoscope,  mode,  use,  and  kinds  of, 
139 
use  of,  in  auscultation  of  heart, 
211 
of  pulse,  257 
of  veins,  268 
in  cardiac  murmurs,  232 
with  venous  humming,  269 
value    of,    in    auscultating   over 

spleen, 340 
when  to  be  used,  140 
Stiff-neck,  539 

Stigmates  hysteriques,  534,  587 
Stimulation,  points  of,  608 
Stintzing,  normal  electrode  by,  502 
reference  to.  354,  502,  503,  512, 
616,  517,  518,  523 
Stohrer,  reference  to,  476,  503 
Stokes,  reference  to,  92,  142 
Stolnikow,  reference  to,  190 
Stomach,    abscess    of    circumscribed 
pain  with,  314 
acute  catarrh  of,  paleness  in,  40 
alkaline  urine  with  dilatation  of, 

413  _ 
amyloid  degeneration  of  mucous 

membrane  of,  356 
anatomy  of,  297 

atrophy  of  mucous  membrane  of, 
356 
passage  of  oil  into  intestine 
in,  354 
auscultation  of,  307 
blood  from,  in  expectoration,  167 
boundary  illustrated,  304 
cancer  of,  peptonuria  with,  439 
catarrh  of,  absorption  from,  364 
superacidity  with,  357 
vomit  in,  360,  361 
closed    tympanitic  sound    heard 

over,  111 
coating  of  tongue  in  diseases  of, 

287 
decomposition  of  contents  of,  356 
digestion  described  at  length,  342 
duration  of,  344 
how  studied,  341 
mode  of  examining,  347 
pathological   disturbance  of, 

344 
prolonged,  346 
value  of  results  of  examina- 
tion of,  366 
dilatation  of,  348 

absorptive  power  in,  355 
causes  of  345 


Stomach  dilatation,  indicated  by  sar- 
cina  and  torulse  in  vomit, 
365 
infrequency  of  the  attacks  of 

vomiting  in,  359 
symptoms  of  with  displace- 
ment of  right  kidney,  396 
with  fermentation  of  contents, 
seething  sound  over,  208 
diseases  of,  in  which  there  is  di- 
minished  or    absence  of   free 
muriatic  acid,  356 
distensibility  of,  300 
disturbance    of,   with    migraine, 

483 
examination  of,  297 
extent   to  which   it  is  parietal, 

299 
fasting,  value  of  examination  of, 

355 
great  amount  of  vomit  in  dilata- 
tion of  360 
-heart  space,  306 
hemorrhage  of,  40,  170 

acid  reaction  of  blood  in,  170 
distinguished  from  that  from 
lungs,  362 
hour-glass,  302 

hypersecretion  in  ulcer  of,  357 
hypertrophy  of  muscular  coat  of, 

346 
inflated,     metallic     heart-sounds 

with,  221 
inflation  for  diagnosis,  300 
inspection  and  palpation  of,  299 

mode  of  299 
-liver  space,  circular,  306 
-lung  sound,  when  heard  over,  113 
space,     circular,    tympanitic 
sound  over,  306 
metallic  sound  over,  112 
method  of  examining  fasting,  355 
movements  of,  part  in  digestion, 

353 
normal  cannot  be  defined  through 

abdominal  wall,  300 
percussion  of,  304 
perforating  ulcer  of,  stool  of  372 
cause  of  pneumothorax,  210 
position  of,  78 
if  dilated,  305 
illustrated,  319 
of  lower     border    of,    illus- 
trated, 327 
of,    when     moderately    full, 
305 


INDEX. 


687 


Stomach-pump,  use  of,  in  washing  out 
the  stomach,  348 
purposes    for  which   it   is   to   be 

emptied,  357 
rapidity  of  passage  of  food  from, 

tests  for,  o54 
resonance  in  region  of  heart  dul 

ness,  206 
rinsing  out,  in  studying  contents 

of,  341 
section   of,  examination  of  con- 
tents of,  341 
significance  of  acid  secretion  of, 

357 
sudden     amaurosis    after    severe 

hemoiThage  of,  602 
superacidity  with  ulcer  of,  357 
symptomatology  of  dilatation  of, 

346 
tests  of  absorptive  power  of,  354 
ulcer  of,  hemorrhage  from,  362 
vertigo  in  diseases  of,  472 
vomiting  in  diseases  of,  358 
washing  out  of,  347,  357 
Stomatitis,  cause  of  enlargement   of 

tongue,  286 
Stone  in  pelvis  of  kidney,  tenderness 

with,  395 
Stool,  acholic,  color  of,  373 
odor  of,  371 
bilious,  described,  373 
bloody,  described,  374 
color,    constituents,    and    admix- 
ture of,  372 
fatty,  described,  374 
Stools,  consistence  and  form  of,  371 
involuntary  discharge  of,  579 

in  attacks  of  epilepsy,  534 
odor  of,  371 

purulent,  when  occur,  376 
reaction  of,  372 
watery,  when  occur,  374 
Strabismus,  defined,  562 

lateral,  divergent,  convergent,  de- 
fined, 563 
Strangling,  from  irritability  of  larynx, 

590 
Strangury,  causes  of,  400 
Strength,  rapid  decline  of,  587 
Streptococci,  in  purulent  pleural  exu- 
dation, 161 
Streptococcus  erysipelatous, described, 
603 
in  urine,  399 
pyogenes,  161 

description  of,  603 


Striae,  52 

from  ascites,  313 
on  abdomen,  cause  of,  314 
Stricture  of  CBsophagus,  location  of, 

295 
Stridor  laryngeus  vel  trachealis,  97 
Strongylus  gigas,  cause  of  pyuria  and 

hsematuria,  425 
Structure  of  body,  33 
Struma,  blowing  murmurs  over  lym- 
phatic glands  in,  259 
Striimpell,    reierence  to,  67,  178,  249, 

250,  440,  466,  478,  535,  554 
Strychnia  poisoning,  increased  tendon 

reflex  in,  500 
Stupor  defined,  470 
Subacidity  in  dilated  stomach,  346 
of  stomach,   efiect  of,   344,  348, 
356 
Subjective  sensibility,  472 
Subphrenic    abscess,  downward    dis- 
placement of  liver   from, 
322,  330 
peritonitis,  diagnosis  of,  317 
Succussion,    Hippocratic,    described, 
156 
pathognomonic  of  hydro-pneumo- 
thorax,  156 
Sudamina,  50 

Sugar,   determination  of,  by  circum- 
polarization,  447 
in  urine,  443 

qualitative  test  for,  444 
quantitative  test  for,  445 
often  in  urine  of  health,  405 
uric  acid  in  urine  hinders  exami- 
nation for,  405 
Sulphuric  acid  in  urine,  435 
Superacidity.     Also  see  Hyperacidity, 
of  stomach,  348 

contents,  when  it  occurs,  351 
diseases  in  wnich  it  occurs, 

357 
effect  of,  344 

free  muriatic  acid  with,  346 
signs  of,  356 
Supersecretion.    Also  see  Hypersecre- 
tion, 
of  gastric  juice,  what  diseases  it 
occurs  with.  357 
Suppression  of  urine,  due  to  venous 
engorgement,  260 
reflex,  of  urine,  408 
Suppuration,  cause  of  paleness,  41 
of  ear  and  nose,  cause  of  menin- 
gitis and  abscess  of  brain,  467 


688 


INDEX. 


Supraclavicular  depression  deepened 
from  contraction   of  apex 
of  lung,  87 
percussion  of,  118,  130 
Supraorbital  nerve,  illustrated,  485 
Suprascapular  nerve,  illustrated,  486 
Supratrochlear  nerve,  illustrated,  485 
Swallowing,  difficulty  of,  in  bilateral 
paralysis  of  soft  palate,  538 
difficulty  of,  in  paralysis,  537 
pain  in,  75 
Sweat.     Also  see  Perspiration. 

accompanies  remission  of  fever,  62 
alterations  of,  38 
cold,  with  dyspnoea,  99 
critical,  in  recurrent  typhus,  70 
diminished,  38 
Sweating,  accompanies  vomiting,  359 
cause  of  diminution  of  urine,  407 
effect  of,  on  color  and  amount  of 

urine,  402 
local,  38 
Syllable- stumbling,  553 
Sylvius,  embolus  of  the  fossa  of,  562 
fissure  of,  artery  of,  462 
fossa  of,  illustrated,  466 
Sympathetic     paralysis,  inequality  of 

pupils  in,  567 
Sympathetica  spastica,  unilateral  vaso- 
motor disturbances  in,  577 
Symphysis   pubis,  significance  of  dul- 

ness  above,  316 
Symptom,   Romberg's,  480 
Symptomatic,  migraine  may  be,  483 

neuralgia,  483 
Symptomatology  of  diseases   of  ner- 
vous system,  section  on,  463 
value  of,  20 
Symptoms,  concealment  of,  19 

direct    and   indirect,   in   nervous 
diseases,  585 
Syncope  defined,  significance  of,  471 
Syphilis,  affecting  larynx,  75 
liver,  324 
change    in    shape   of  liver  from 

scars  of,  325 
changes  in  fundus  oculi  with,  601 
chronic  catarrh,  a  sign  of,  74 
cicatrices  of,  dyspnoea  from,  93 
concealed,  19 
congenital,  Hutchinson's  teeth  a 

sign  of,  286 
constitutional,  paleness  in,  41 
cracks  in  lips  of  children,  a  sign 

of  hereditary,  285 
deformed  nose  from,  73 


Syphilis,  diagnosis  of,  when  brain  and 
spinal  cord  are  affected,  586 
glands  of  neck  enlarged  in,  291 
haemoglobin  in  urine  of,  411 
hereditary,  early  signs  of,  22 
infectious  in  utero,  20 
inherited,  29 
irregular    enlargement    of    liver 

with,  322 
may   be  a  cause  of   catarrh  of 

larynx,  693 
middle  ear  catarrh  in,  572 
mucous   patches    in    mouth    in, 

288 
nervous  diseases  from,  581 
neuralgia  from  poison  of,  483 
nocturnal  headache  with,  482 
nose  affected  in,  576 
primary  and  secondary  outbreaks 

of,  22 
scars  of,  52 

on  tongue  from,  288 
sterility  caused  by,  21 
subcordal  laryngitis  from,  593 
tonsils  in,  290 

ulceration  of  larynx  with,  595 
Syphilitic  formations  of  tongue,  286 
gummata  on  liver,  326 

on  skull,  465 
infiltration     and    ulceration     of 
larynx,  592 
difficulty  of  diagnosis  of,  595 
iritis,  562 

scars  in  larynx,  596 
Syringo-myelitis  of  cervical  cord,  582 
trophic  disturbance  of  bone 
in,  583 
Systole  of  heart,  collapse  of  veins  with, 
264 
movement  of  blood  in,  193 
sound  with,  212 
Systolic  drawing-in,  267 

near  apex  of  heart,  202,  204, 
220 
heart-sound,   what    due    to  and 

where  heard  best,  213,  214 
murmur,  252 
at  apex,  251 
heard  with   aortic    stenosis, 

258 
over  pulmonary  artery,  when, 
255 
^     with  atheroma  of  aorta,  254 
murmurs,  222,  225 

how  distinguished  from  dias- 
tolic, 226 


I  AD  EX. 


689 


Systolic,  positive  venous  pulse  is,  264  [  Taenia  mediocanellata  described,  378 


sound  in  health  over  large  arte 
ries,  257 

subclavian  murmur  described  and 
explained,  259 

trembling   and  pulsation  in  epi- 
gastrium, 204 

true  venous  pulse,  rare  in  facial 
veins,  267 

venous  pulse,  266 

with  mitral  insufficiency, 
267 

vesicular  breathing,  143 


T  abbreviation  for  tetanic  contrac- 
,     tion. 
Tabes,  allochiria  in,  478 
arthropathia  in,  583 
atrophy  of  optic  nerve  in,  601 
bladder  crises  (painful  tenesmus) 
in,  580 
disturbance  in,  580 
brittleness  of  bones  in,  583 
cystitis  with,  579 
decline  of  genital  function  in,  580 
dorsalis,  ataxia  the  most  impor- 
tant symptom  of,  529 
atrophy  of  optic  nerve  in,  562 
contracted  pupil  with,  566 
diminished     tendon    reflex 

(very  important),  500 
mydriasis  in,  566 
feeling  of  constriction  about  tho- 
rax in,  482 
gastric  crises  with,  578 
herpes  zoster  with,  581 
hypersecretion  of  stomach  in,  357 
inequality  of  the  pupils  in,  567 
intestinal  crises  with,  578 
laryngeal  spasm  with,  576 
laxness  of  muscles  in,  494 
location  of,  484 
mal  perforanc  in,  582 
migraine  in,  483 
neuralgia  in  initial  stage  of,  483 
pain  in  spine  with,  483 
polyuria  and  glucosuria  in,  579 
residual  urine  with,  408 
tenderness  of  vertebrae  in,  467 
vomiting  in,  361 


illustrated,  379 
solium,  cysticerci  in  brain  from, 

578 
described,  377 
eggs  of,  described,  378 
parts  of,  illustrated,  378 
poikilocytosis  in,  277 
Talma,  reference  to,  151 
Taste,  mode  of  testing  the  sense  of,  574 

sense  of,  location  of,  461 
Teale,  reference  to,  62 
Teeth  and  gums,  examination  of,  285 
caries  of,  in  diabetes  mellitus,  285 
condition  of,  in  poisoning  by  mer- 
cury, lead,  copper,  286 
in  scorbutus,  286 
diseased,  a  cause  of  dyspepsia,  286 
disturbances    which    accompany 

eruption  of,  286 
Hutchinson's  sign  of  congenital 
syphilis,  286 
Temperament,  effect  upon  pulse,  235 
Temperature.     Also  see  Fever 

an  index  of  severity  of  disease,  61 
chart,  value  of  pulse  record  on,  253 
course  of  62 
daily  variations  of  60 
dangerous  to  life,  61 
diagnostic  value  of,  section  on,  64 
diminution  of,  when  occurs,  575 
efi'ect  of,  on  perspiration,  36 
exacerbation  of,  62 

complication  shown  by,  65, 67 
fall  of,  collapse  with,  70 
sign  of  collapse,  67 
frequency  of  taking,  59 
highest  observed,  62 
local,  71 
lowering  of,  71 
normal,  variations  of,  59 
relation  to  pulse  not  constant,  61 
remission  of,  62 
section  on,  57 
subnormal,  section  on,  63 
table  of,  61 
taking  of,  methods,  58 
tracing  of,  with  pulse,  236 
unilateral  elevation  of  in  hysteria, 

71 
variations  of  pulse  due  to  external, 
235 


Tables  of  comparison  of  the  two  sides 

of  the  body,  with  faradic  and  gal-    Temporal  artery,  pulsation  in,  256 
vanic  current,  517  '  convolutions,   second   and  third, 

Tseuiacucumerina,  described  and  illus-  \  blood  supply  of,  462 

trated,  380  [         lobe,  461 

44 


690 


INDEX. 


Temporal  lobe,  illustrated,  466 
Tenderness  of  intestine,  kinds  of,  and 
diseases  with,  308 
of  liver,  when  manifest,  324 
of  nerve  during  neuralgia,  484 
of  region  of  kidney,  when  occurs, 
395 
Tendo-Achillis   reflex  and  foot  phe- 
nomenon  defined,  how  tested,  sig- 
nificance of,  499 
Tendon  reflex,  493 

an  attendant  phenomenon  of 

spasms,  494 
increase  and  diminution  of, 
goes  parallel  with  tonus,  500 
increased  in  the  phenomenon 
of  paradoxical  contrac- 
tions, 527 
in  partial  epilepsy,  533 
mechanism     of,     illustration 

explained,  500 
mixture  of,  and  direct  mus- 
cular irritation,  501 
of  upper  extremities,  499 
seat  of,  528 
when  increased,  500 
reflexes,  aid  in  diagnosis,  498 
importance  of,  497 
section  on,  497 
when  diminished  or  lost,  500 
Tenesmus  at  stool,  370 

of  bladder,  cause  of,  400 
Tension  diminished,  gives  deep  nou- 
tympanitic  sound,  112 
of  lung  tissue  diminished,  135 

effect  on  pitch,  112 
of  wall  of  closed  air  cavity,  effect 

on  pitch  of  sound,  110 
of  walls,    effect   upon    change  of 
pitch  of  sound,  111 
Terminal  arteries,  defined,  462 
Test  papers,  Geisler's  albumin,  436 
Testing  the  sensibility  to  irritation,  473 
Tetanus,  cyanosis  in,  44 
dyspnoea  in,  95 
fever  with,  575 
galvanic,  505 
increased  excitability  in,  526 

tendon  reflex  in,  500 
opisthotonus  with,  468 
tonic  and    clonic   spasm  of  tho- 
racic muscles  in,  540 
spasms  in,  532 
Thallin,  urine  after  taking,  451 
Thermsesthesiometer,  use  of,  475 
Nothnagel's,  described,  475 


Thermometer,  selection  of,  58 
Thermometers,  scales  of,  57 
Thermometric  scales,  comparison  of,61 
Thigh,  points  of   electrical  irritation 
of,  illustrated,  511 
-sound,  109 

associated    with    feeling    of 

strong  resistance,  116 
defined,  106 
term  used  for  dull,  108 
when  heard,  113 
Third  nerve,  paralysis  ot,  566 
Thirst,  in  febrile  diseases,  287 
Thoma-Zeiss's  apparatus  for  counting 

blood  corpuscles,  274 
Thompson,  reference  to,  286 
Thomsen's  disease,  493 

myotonic  reaction  in,  518 
Thoracic  breathing  aided  by  auxiliary 
muscles,  99 
conditions  that  abolish  it,  91 
replaced  by  diaphragmatic,  90 
diseases,  position  in  bed  in,  32 
duct,  compression  of,  a  cause  of 

chylous  ascites,  318 
organs  and  deformities  of  chest, 

81 
pain  produced  by  pressure,  101 
viscera,  position  of,  78,  79 
Thorax,    anatomical  prominences  of, 
76 
circumference  of,  increased  in  in- 
spiration, 163 
where  measured,  162 
covering  of,  effect  of,  on  heart- 
sounds,  216 
cross-section  of,  163 
deformity  of,  a  cause  of  disloca- 
tion of  heart,  199 
larger    parietal   area    of 
heart,  200 
effect   of  elasticity  of,  on  heart- 
sounds,  216 
emphysematous,  85 
examination    of,    in    connection 
with  disease  of  oesophagus,  296 
flexibility  of,  83 
flexible  projection  of,  in  diseases 

of  the  heart,  203 
form  of,  81 

important,  33 
frequent  measurements  of,  value 

of,  163 
inspection  of,  81 
inspiratory  enlargement  of,  83 
length  of,  163 


INDEX. 


691 


Thorax,  local  expansions  of,  86 
measurement  of,  162 
one-sided  extension  of,  85 
palpation  of,  100 
paralytic,  described,  84,  85 
pathological  forms  of,  83 
percussion  of,  described,  118 
phthisical,  often  absent  in  phthi- 
sis, 85 
right  side  measures   more  than 

left,  168 
rigid,  causes  of,  91 

diaphragmatic      breathing 

with,  91 
prevents    projection   in    en- 
largement of  liver,  321 
short,  position   of  apex-beat  in, 
198       _ 
tympanitic  resonance  in  re- 
gion  of  heart-dulness   in, 
206 
sound  on  percussing,  109 
tumors  of,  measurement  of  thorax 

in,  163 
value  of  pulse  in  deformity  of,  253 
repeated  measurement  of,  in 
aneurism  of  aorta,  254 
wall  of,  dulling  effect  on  heart- 
sounds,  217 
yielding,  in  children,  98 
Throat  and  neck,  muscles  of,  538 
Thrombosis,  effect  upon  pulse  in  one 
of  two  symmetrical  vessels,  257 
local  low  temperature  in,  71 
of  large  veins  of  lower  extremities, 

268 
of  veins  a  cause  of  cyanosis,  45 
renders  deep  veins  accessible,  260 
venous,  effects  of,  262 

when    and  where  it   occurs, 
268 
Thrombus,    closure   of  venous  trunk 

by,  261 
Thrush,  description  of,  287 

in  children,  spores  in  feces,  388 
microscopic  appearances  of,  290 
stenosis  of  oesophagus  from,  296 
Tinnitus   aurium,    sometimes   a   pre- 
cursor  of    migraine,   apo- 
plexy, or  epilepsy,  573 
with  migraine,  483 
Tobacco  amblyopia,  602 

central  scotoma  in,  569 
use  of,  effect  on  disease,  21 
Toes,  paralysis  of  muscles  of,  547 
Toluylendiamin,  poisoning  by,  caus- 
ing hsemato-jaundice,  47 


Tone,  as  applied  to  heart-sounds,  212 
of  heart-sounds,  variations  of,  216 
pitch  of,  how  effected,  109 
Tongue  and  soft  palate,  electrical  irri- 
tation of,  510 
coating  of,  287 
color  of,  287 
dryness  of,  287 
enlargement  of,  286 
examination  and  conditions  of,286 
in  typhoid  fever,  287 
motor  centre  for,  454 
muscles  of,  536 

that   move   it,  and   effect  of 
their  paralysis,  537 
nerve-supply    of   anterior    two- 
thirds  of,  484 
normal  mobility  of,  in  hysterical 

dumbness,  548 
not  bitten  in  hysterical  spasms, 

534 
often  bitten  during  attack  of  epi- 
lepsy, 533 
sense  of  taste  in,  461 

anterior  two-thirds  from 
the  chorda,  and  poste- 
rior   one  -  third    from 
glosso-pharyngeus,574 
taste  in  the  anterior  portion  of, 
affected  in  paralysis   of  facial 
nerve,  461 
trembling  of,  in  alcoholism,  fevers, 

and  typhus,  287 
wounds  of,  287 
Tonic  spasms,  530 

when  occur,  532 
Tonus  of  muscles,  488,  496,  528 
disturbance  of,  489 
method  of  testing  when  only 
slightly  increased,  501 
of  paralyzed    muscles   increased, 

494 
of  quadriceps,  increased,  disturbs 
patellar  reflex,  498 
Tonsils,   condition    of,    in    tonsillitis, 
syphilis,  diphtheria,  etc.,  290 
crvstals  in  sputum  from  inflamed, 

■l81_ 
offensive  plugs  from  lacunae  of, 
171,  174 
Tooth-mucus  bacillus,  like  comma  ba- 
cillus, 391 
Topographical  percussion  defined,  and 
uses  of,  116 
relation  between  surface  of  brain 
and  skull,  illustrated,  466 
Topography  of  abdomen,  297 


692 


INDEX. 


Torula  cerevisiae,  in  fever,  388 
in  vomit,  365 

with  normal  digestion,366 
Touch,  sense  of,  how  tested,  473 
Toxic  headache,  causes  of,  483 

influences,  neuralgia  from,  483 
paralyses,  EaR  with,  524 
Trachea,  casts  of,  in  sputum  of  croup, 
172 
change  of  sound  in,  130 
distance   of  bifurcation  of,  from 

incisor  teeth,  291 
epithelium  in  sputum  from,  176 
mucous  rales  in,  165 
normal  sound  over,  119 
open  tympanitic  sound,  when  it 

is  percussed,  110 
sensitiveness  of,  a  cause  of  cough, 

165 
stenosis  of,  97 

inspiratory    drawing -in    of 
chest  wall  in,  98 
tympanitic  sound  over,  121,  130 
ulceration  of,  a  cause  of  emphy- 
sema of  skin,  56 
Tracheal  change  of  sound  explained, 
132 
sequestra  of,  in  sputum,  172 
tone,  Williams's,  described.  111, 
131 
Transfusion  of  blood,  haemoglobin  in 

urine  after,  411 
Transition  breathing,  148,  149 

corresponds  to  hinted  rales, 
153 
Transparency  of  expectoration,  168 
Transudation,  diagnosis  of,  from  exu- 
dation, 160 
Transudations,  effect  of  absorption  of, 
on  reaction  of  urine,  413 
increase  of  chloride  of  sodium  in 
urine  with,  434 
Trapezius  muscle,  paralysis  of,  eflFect 

of,  541 
Traube,  reference   to,  104,  151,  179, 

259,  306,  440 
Traumatic  hemorrhages,  51 

hysteria,    narrowing  of   field    of 

vision  in,  569 
paralysis,  EaR  in,  525 
Traumatism,   exposure  of  nerves  to, 

468 
Treatment,  vaHie  of  pulse  in,  showing 

result  of,  253 
Trembling  (tremor),  530 
Tremor,  graphic  representation  of,  531 


Tremor,  mercurialis,  531 
saturninus,  531 
senilis,  531 
with  hysteria,  531 
Trichina  spiralis  described,  383 
importance  of,  383 
illustrated,  384 
Trichinae  in  stools,  383 

in  vomit,  364 
Trichinosis,  383 

cyanosis  with,  44 
Trichomonas  vaginalis,  found  in  urine, 

425 
Tricocephalus   dispar,  described  and 

illustrated,  383 
Tricuspid  insufficiency,  194,  195 

case  of  relative,  referred  to, 

266 
double  sound  with,  over  crural 

vein,  268 
murmur  of,  where  heard,  225 
positive  venous  pulse  pathog- 
nomonic of,  264 
relative,   pulmonary    second 

sound  in,  218 
venous  murmur  with,  268 
murmur,  where  heard,  224 
stenosis,  194 

venous  engorgement  from, 261 
valve,   causes  a  systolic    sound, 
213,  214 
Trigeminus  nerve,  461 

anosmia  due  to  paralysis  of, 
574 
sense  of  taste  in  anterior  portion 
of  tongue  affected  in  disease  of, 
461 
Triple-phosphates,  deposit  of,  in  urine, 
402 
illustrated,  430 
in  sputum,  182 
in  urine  described,  431 
Trismus,  masseter  spasm  in,  532 
Trommer's  test  for  sugar,  444 

used  in  estimating  amount  of 
sugar,  446 
Tropaolin-paper,  use  of,  in  testing  for 

free  muriatic  acid,  350 
Trophic  influences  of  the  cortical  cen- 
tres, 456 
Trunk,  muscles  of,  and  efiect  of  their 
paralysis,  539 
nerves  of,  485 
Tubercle  bacilli,  illustration  of,  184 

in  sputum  in  tuberculosis  of 
larynx,  595 


INDEX. 


693 


Tubercle  bacilli,   mode   of  examina- 
tion, 185 
only  present  with  disintegra- 
tion, 161 
staining  of,  186,  187 
bacillus,  cultures    of,    described, 
605 
in  blood,  rare,  281 
in  feces,  presence  explained, 

391 
in  pleural  exudation,  161 
in  sputum,  175 
in  urine,  illustrated,  426 

sign   of   tuberculosis   of 
urinary  passages,  426 
Tubercular  cachexia,  41 

deposits,  small  tympanitic  sound 

over,  130 
peritonitis,  315 

enlargement  of  spleen  in,  335 
surface  of  liver  in,  325 
tenderness  of  the  liver  with, 
324 
ulceration,   result  of  infiltration 
in  larynx,  595 
Tuberculosis,  82.     Also  see  Phthisis 
acute  miliary,  of  lung  and  pleura, 
friction  sounds  with,  155 
pulse  in,  239 
affections  of  ear  with,  572 
cachexia  of  oxaluria  with,  430 
catarrh  of  larynx  in  tuberculosis 

of  lungs,  593 
Charcot-Leyden's  crystals  in  spu- 
tum of,  182 
choroidal,  562,  601 
chronic,  Curschmann's  spirals  in 
sputum  of,  180 
remittent  fever  of,  68 
color  of  face  in,  42 
crystals  of  cholesterin  in  sputum 

of,  181 
deepening  of  clavicular  depression 

in,  87 
diagnosis  of,  by  aid  of  microscope, 

291 
disposition  to,  with  narrow  chest, 

34 
,  dyspnoea  in,  95 
effect  on  weight,  36 
elastic  threads  in  the  sputum  of, 

177 
fever  in.  65 
fibrin  in  urine  in,  439 
forms   of  fat   found  in  feces  in, 
386 


Tuberculosis  in  apices  of  lungs,  with 
cavities,  131 
indicated  by  scrofulosis,  22 
infections  in  utero,  21 
inherited,  20 

intestinal,  feces  contain  Charcot's 
crystals,  388 
infusoria  found  in  stools  of, 

384 
tenderness  with,  308 
miliary,  petechise  in,  50 
of  apex  of  lung,  increased  vascu- 
lar breathing  in,  144 
prolonged  expiration  in,  145 
of  apices,  pain  with,  102 
of  larynx,  75 
of  lungs,  22 

disturbance  of  the  circulation 

through  them,  44 
night-sweats  of,  38 
shown  by  tubercle  bacillus, 
187 
of  lymphatic  glands,  effect  on  ab- 
sorption of  fats,  371 
of  pericardium,    friction    sounds- 

with,  232 
of  peritoneum,  little  or  no  pain 

with,  314 
of  pleura,  a  cause  of  tenderness, 

101 
of  tonsil,  290 
of  urinary  apparatus,  398,  426 

shreds  of  tissue  in  urine 
of,  421 
passages,  400 
pulmonary  hemorrhage  in,  170 
red  border  upon  gum  in,  286 
shrinking  of  omentum  in,  340 
thrush  with,  288 
tracing  of  pulse  of,  248 
tympanitic  sound  over  apices  of 

lungs  in  beginning  of,  112 
ulceration  of  larynx  with,  595 
weight  of  body  in,  35 
with  paralytic  thorax,  85 
Tuberculous  and  syphilitic  laryngitis, 
differential  diagnosis  of,  593 
infiltration  and  ulceration  of  lar- 
ynx, 592 
Tumor  of  kidney,  tenderness  with,  395 
of  liver  or  spleen,  306 
of  lungs,  peculiar  sputum  of,  171 
Tumors,  abdominal,  effect  on  form  of 
thorax,  86 
tympanitic  sound  near,  130 
cause  of  venous  stasis,  262 


694 


INDEX. 


Tumors,  cause  of  inspiratory  dyspnoea, 
99 
cerebral,  slow  pulse  with,  237 
conceal  apex-beat,  201 
glandular,  cause  of  pressure  on 

nerves,  469 
in  chest  cavity,  dyspnoea  from,  95 
in  lungs,  weak   percussion  over, 

115 
intestinal,  percussion  of,  312 
intra- tracheal,  dyspnoea  with,  93 
neuralgia  from  pressure  of,  483 
of  brain,  disturbance  of  conscious- 
ness with,  471 
sensibility     of    cranium    to 
pressure  with,  466 
of  chest  cavity,  bronchial  breath- 
ing from,  146 
diagnosis   of,  by  punct- 
ure, 160 
wall,     cause     of     deadened 
sound, 130 
pulse  in,  253 
of  intestine,  diagnosis  of,  310 

kinds  of,  310 
of  kidney,  described,  394 
diagnosis  of,  397 
value  of  percussion  with,  397 
of  pleura,  one-sided  expansion  of 

chest  in,  86 
of  stomach,  dullness  over,  306 
and  spleen,  respiratory  mo- 
tion of,  322 
pulsation  with,  302 
of  thorax,  irregular  boundary  of, 
129 
measurement  of  thorax  in, 
163 
of  tongue,  a  cause  of  enlargement, 

286 
of    transverse     and     descending 
colon    easily  confounded   with 
those  of  spleen  or  kidney,  311 
of  vertebrae,  tenderness  of,  467 
of  wall  of  stomach,  300 
near  stomach  not  felt,  303 
pressure  of,  a  cause  of  jaundice, 
46 
Turbinated  bones,  enlargement  of,  a 

cause  of  neuroses,  575 
Tiirck,  reference  to,  594 
Tiirck's  reflector,  589 
Turpentine,  odor  of  urine  after  taking, 

414 
Tympanites,  effect  of,  upon  extent  of 
abdomen,  309 


Tympanitic  deadened  sound,  131 

resonance  in  region  of  heart-dul- 
ness,  206 
near  an  infiltrated  lung,  126 
near  heart,  when,  210 
open   or    closed,  over    lung 

cavities,  131 
over  lung    containing   scat- 
tered deposits,  127 
with   high  tension   of  lung- 
tissue,  135 
sound  further  defined,  109 
intensity  of,  109 
just  above  large  exudation, 

128 
musical  pitch  of,  109 
occurs  with  lack  of  tension 

of  lung-tissue,  110 
on  right  side  of  chest  over 

stomach  or  colon,  121 
over    apices    in     beginning 
tuberculosis,  112 
diseased  lungs,  causes  of, 

130 
larynx  and  trachea,  121 
where  heard,  109 
with  pneumothorax,  154 
with    retracted     lung,     111, 
112 
sounds,  107 
Typhlitis  described,  315 
recurrence  of,  22 

tenderness    in    iliac   fossa  with, 
308 
Typhoid  fever,  ve^  Typhus  abdominalis 
abscess  of  abdominal  muscle 
in,  309 
of  muscles  in,  54 
bacillus  of,  cultures  of,  605 
described  and  illustrated, 

391 ,  605 
found  in  blood  in,  281 
staining  of,  605 
consciousness,  disturbance  of, 

in,  470 
cough,  absence  of,  165 
feces    of,   contain    Charcot's 

crystals,  388 
glucosuria  in,  443 
haemoglobin  in  urine  of,  411 
headache  in,  483 
hemorrhage    in,    shown    by 
temperature,  65 
subcutaneous  in,  51 
ileo-csecal  cooing  in,  312 
infusoria  in  stools  of,  384 


INDEX. 


695 


Typhoid  fever,  intestinal  hemorrhage 
in,  375 

tenderness  in,  308 
leucin  and  tyrosin   in  urine 

of,  432 
leucocytosis  in,  278 
mental  condition  in,  32 
paralytic  chest  from,  85 
peptonuria  in,  439 
posture  in,  32 
pulse  in,  238,  239 

tracing  of,  247 
rash   of,    resembling    scarlet 

i'ever,  50 
recurrence  of,  50 
roseola  in,  49 
spleen,    enlargement    of,   in, 

334 
spermatozoa     in     urine     in, 

421 
staphylococcus   pyogenes  in 
the  suppuration  which  ac- 
companies, 603 
stools  thin  in,  371 
sweat  in  remittent  stage  of, 

38 
temperature,  course  of,  65 

variation  of,  in,  66 
tongue,  state  of,  in,  287 
tympanitis  in,  309 
ulceration  of  the  larynx  in, 
595 
Typhus    abdominalis.     See    Typhoid 
Fever 
fever,  cutaneous  hemorrhages 
with,  51 

eruption  of,  49 
typical  course   of  fever 
in,  65 
Tyrosin,  form  of,  in  urine,  432 
in  sputum,  182 
in  urine,  illustrated,  431 
when  occurs,  432 


UFFELMANN'S    test    for    lactic 
acid,  351 
Ulcer  of  stomach,  blood  in  stool  from, 
375 
hemorrhage  from,  362 
pain  in,  303 
superacidity  with,  357 
supersecretion     of    stomach 
with,  357 
Ulceration    of   larynx,    seldom   with 
catarrh,  595 


Ulceration  of  larynx,  voice  in,  74 

of  trachea  and  bronchi,  172 
Ulcerations,  deep,  of  skull  wall,  465 
internal,  a  cause  of  emphysema 
of  skin,  56 
Ulnar  nerve  illustrated,  486 

distribution  to  hand,  545 
electrical  examination  of,  511 
position  of  the  hand  in  par- 
alysis of,  544 
neuritis  from  fracture  of  internal 
condyle   of  humerus,  case  of, 
469 
Ultzmann,  reference  to,  429 
Umbilical  region,  illustrated,  298 
Unconsciousness,  catheter   always  to 
be  used  to  draw  the  urine,  401 
faradic  test  of,  476 
involuntary    discharge    of  urine 
during,  579 
Undefined  breathing  explained,  148 
Unequal  pulse  in  symmetrical  vessels, 
significance  of,  257 
respiration,  92 
Ungar,  reference  to,  182 
Unilateral  convulsions  in  partial  epi- 
lepsy, 533 
skin  reflex,  495 
Unverricht,  reference  to,  153,  154 
Upper  extremities,  tendon  reflex  of, 

499  _ 
Uraemia,   ammoniacal   odor  of  vomit 
in,  366 
Cheyne  Stokes  breathing  in,  92 
coma  from,  440,  470 
defined,  440 
dyspnoea  in,  576 
epileptiform  spasms  in,  533 
headache  with,  483 
slight  amount  of  vomit  with,  360 
symptoms  of,  440 
urea  diminished  in,  434 
vomiting  in,  358 
Ursemic  amaurosis,  601 
Urate  of  ammonia,  form  of,  in  urine, 
432 
illustrated,  430 
in  urine,  402 
of  soda  and  lime,  described,  429 
Urates,  precipitation  of,  by  albumin 

test-papers,  437 
Urea,  amount  of,  in  twenty-four  hours, 
405 
cannot  be  determined  from  spe- 
cific gravity  of  urine,  412 
increase  of,  433 


696 


INDEX. 


Urea  in  saliva  in  nephritis,  289 

method   of  determining  amount 

of,  434 
quantitative     determination      of, 
value  of,  413,  434 
Ureter,    obstruction    in,   a  cause    of 
diminished  secretion  of  urine,  407 
one,  stopped  up  in  tuberculosis,400 
Ureters,  examination  of,  398 
Urethra,  diminished  amount  of  urine 

from  stricture  of,  408 
Uric  acid  as  a  urinary  sediment  de- 
scribed, 428 
concretions  of,  433 
crystals  of,  illustrated,  429 
diathesis,    increase    of    uric 

acid  in,  434 
found  in  blood  in  gout,  283 
hinders      examination      for 

sugar,  405 
salts,     separation     of,     from 

cooled  urine,  402 
source  of,  in  urine,  405 
when  increased,  434 
Uridrosis  defined,  38 
Urinary  apparatus,  chapter  on  exami- 
nation of,  392 
disturbances  of,   section  on, 

579 
examination  of,  what  it  com- 
prises, 392 
"calculi,  cause  of,  429 
casts,  most  important  element  in 

pathological  urine,  421,  422 
constituents  in  solution,  433 

anomalies  in  amount  of,  433 
diseases,  sweat  in,  38 
passages,    deep-seated   inflamma- 
tion of,  fibrin  in  urine  of,  439 
products  in  fever,  408,  416,  422, 

423 
sediments,  404 

examination  of,  415 
of  organic  bodies,  416 
Urination,     assisted     by     abdominal 
pressure,  540 
frequent  causes  of,  400 
Urine,  acidity  of,  how  determined,  414 
affected  by  medicines,  450 
always  to  be  drawn  with  catheter 
when  there  is  unconsciousness, 
401 
amphoteric  reaction  of,  404 
anomalies  in  amount  of,  406 
causes  of  diminution  of  (anuria), 
407 


Urine,  clear,  to  be  tested  for  sugar  if 
specific  gravity  is  high,  443 
color    and    transparency    of,    in 

disease,  401,  408 
complete  diminution  of  (anuria), 

407 
concentrated,  appearance  of,  402 

effects  of,  400 
concretions  in,  433 
contains  bile  in  jaundice,  46 
contamination  of,  how  to  avoid, 

399 
daily  average  amount  of,  401 
determining  amount  of  nitrogen- 
ous material  in,  value  of,  434 
diminution  of,  in  fever,  60,  407 
discoloration  of,  causes  of,  410 
examination  of  section  on,  399 
fermentation  of,  effect  of,  on  its 
appearance  and  character,  402 
increase  in  pigments  of,  409 
in  uro-genital  tuberculosis,  426 
involuntarily   discharged    in   at- 
tacks of  epilepsy,  534 
involuntary   discharge   of,  when 

occurs,  579,  580 
mode  of  procedure  in  examining, 

400 
normal,  section  on,  401 
odor  of,  404 

due  to  medicines,  414 
pathological  odor  of,  415 
section  on,  406-450 
reaction  of,  generally  acid,  403 

in  disease,  413 
retention  and  incontinence  of,  400 
rule  for   approximation  of  solid 
constituents  from  specific  grav- 
ity, 412 
secretion  of,  less  at  night,  401 
soluble    constituents    of,   named 

and  described,  404 
specific  gravity  of,  how  measured, 
403 
when  diminished,  413 
staining  of,  from  medicines,  411 
suppression  of,  causes  of,  407 

due  to  venous  engorgement, 
260,  261 
table  of  colors  of,  useless,  408 
turbidness  of,  when  passed  is  pa- 
thological,  and   when    occurs, 
411 
Urobilin,  coloring  pigment  in  urine, 
402,  409     • 
-icterus,  48,  409 


INDEX. 


697 


Urobilin,  tests  for,  410 

origin  of,  48 
Urobilinuria,  46 
Urometer,  requisites  of,  403 
Uterus,  diseases  in  utero,  20,  21 
Uvse  ursi,  color  of  urine  after  taking, 

411 
Uvula,  position  of,  in  paralysis  of  soft 

palate,  537 


VAGI,  compression  of;  599 
Vagina,  taking  temperature  in, 
68 
Vaginal  mucus  in  urine,  416 
Vagus  centre,  457 

slow  pulse  in  irritation  of, 
237 
irritation  of,  by  bronchial  tumors, 

576 
nerve,  weakness  of  heart-sounds 

in  paralysis  of,  218 
paralysis  of,  pulse  in,  240 
quick  pulse  in,  577 
Valleix's  points   of  tenderness,  101, 

484 
Valve,  insufficiency  of,  eflPect  of,  194 

stenosis  of,  effect  of,  194 
Valves  of  heart,  part  taken  by,  in  the 
heart-sounds,  213 
where  best  auscultated,  213, 
214 
Valvular  defects    revealed    by  mur- 
murs, explanation  of,  221 
deficiency  a  cause  of  cyanosis,  44 

compensation  for,  195 
disease  of  heart,  haematuria  with, 
417,  418 
enlargement     of     liver 
with,  324 
incompensation    in,  a  cause 
of  diminished   amount  of 
urine,  407 
value  of  pulse  in,  252 
insufficiency  and  its  effects,  193 
relative,  murmurs  with,  230 
sound  in  jugular  vein,  265 
Varicella,  49 
Variola.     Also  see  Smallpox. 

ulceration  of  larynx  with,  595 
Vasomotor  centre,  pulse  in  irritation 
of,  245 
disturbances,  when  occur,  577 
influences  upon  pulse  in  symmet- 
rical vessels,  257 
Vegetable  parasites  in  urine,  425 


Vegetative    system,  disturbance    of, 
in    nervous    diseases,   section    on, 
575 
Vein,  portal,  enlargement  of  spleen  in 

occlusion  of,  335 
Veins,  auscultation  of,  268 
examination  of,  260 
of  abdomen,    enlarged  with  as- 
cites, 314 
of  skin  enlarged  in  aneurism  of 

aorta,  254 
phenomena  of  circulation  in,  267 
Vena  cava  inferior,  pressure  upon  by 
enlarged    retro-peritoneal    glands, 
341 
Venereal  excesses,  cause  of  disease,  21 
Venous  engorgement,  effect  on  color 
of  the  blood,  270 
effects  of,  260 
enlargement  of  spleen  with, 

335 
of  tongue,  286 
humming  explained,  269 
louder  on  right  side,  269 
synonyms  for,  269 
when  occurs,  269 
-liver  pulse,  266 

with  enlarged  liver,  322 
pulse  described,  263 

double  positive,  in  hemisys- 

tole,  267 
positive,  tracing  of,  265 
progressive,  in  aortic  insuf- 
ficiency, 267 
in  veins    of   hand   and 
back  of  foot,  268 
tracing  of,  264 
stasis  a  cause  of  jaundice,  47 
a  cause  of  oedema,  64 
ecchymosis  from,  51 
thrombosis,  when  and  where  oc- 
curs, 268 
Ventricle,  contraction  of,  causes  a  sys- 
tolic heart-sound,  213 
hypertrophy  of,  shown  by  streng- 
thened sound  of  corresponding 
valve,  217 
left,  hypertrophy  and   dilatation 
of,  shown  by  displacement  of 
apex,  200 
Vermiform  appendix,  317 

inflammation      of,     Cheyne- 

Stokes  breathing  in,  92 
tenderness  in  disease  of,  308 
usually  no  tumors  with  in- 
flammation of,  316 


698 


INDEX. 


Vertebrae,  spines  of,  sensitive  to  pres- 
sure, 467 
Vertebral  artery,  461 

column,  section  on,  467 
Vertigo,  also  see  Dizziness 

defined,  and  when  occurs,  472 
from  the  eye,  663 
Vesicular  breathing  described,  142 
diminished,  causes  of,  145 
origin  of,  142 

pathological  changes  of,  144 
special  peculiarities  of,  143 
Vicarious  action  of  centripetal  influ- 
ences in  coordination,  528 
of   diaphragm    in    defective 

thoracic  breathing,  540 
of  kidney,  408 
participation      of      neighboring 
nerves,  485 
of  nerve,  479 
Vidian  nerve,  461 
Vierordt,  C,  reference  to,  275 
Vierordt,  H.,  reference  to,  35,  217,  283 
Vierordt,  K..  reference  to,  246,  272 
Vierordt,  O.,  reference  to,  154, 180 
Virchow,  reference  to,  177 
Vision,  concentric  limitation  of,  587 
of  the   field  of  in  gross 
hysteria,  534 
narrowing  of  field  of,  569 
disturbance  of,  from  choked  disc, 

amount  of,  600,  601 
disturbances  of,  in  diseases  of  the 
nervous  system,  562 
in  ursemia,  440 
subjective  sensations  of,  571 
testing  field  of,  568,  569 

for  central  sharpness  of,  568 
Visual  amnesia,  552, 
'  Vocal  cords,  position  of,  during  pho- 
nation,  592 
in  paralysis,  599 
fremitus,  aid  in  determining  appa- 
rent enlargement  of  heart, 
210 
aids    in    diagnosis    between 
pneumonia    and    pleuritic 
exudation,  158 
increased,  when,  158 
palpation  for,  100 
described,  156 
technique  of.  157 
variations  of,  157 
weakness  or  suppression  of, 
when  occurs,  157 
Vogel,  reference  to,  408 


Voice,   character  of,  in   paralysis  of 
muscles  of  speech,  548 
effect    upon,    from    paralysis    of 

laryngeal  muscles,  538 
in  disease,  74 
Voit,  C,  reference  to,  434 
Volume  of  air  cavity,  effect  upon  pitch 
of  sound,  109 
of  an  extremity,  measurement  of, 

490 
of  cavity,  effect  upon  change  of 
pitch  of  sound.  111 
if   closed,    effect    on    pitch, 
110 
of  muscles,  diminution  of,  491 
Voluntary  motion,  455 

muscle,  spasms  of,  530 
Vomicae,    131.     Also  see  Cavities  in 

Lungs. 
Vomit,  chemical  examination  of,  359 
coffee-ground,  test  for  heemin  in, 

363 
color  of,  360 
comma    bacilli    in,   in    cases   of 

cholera  Asiatica,  390 
microscopical  appearance  of,  360 

examination  of,  364 
odor  of,  value  of,  366 
quantity  of,  360 
reaction  of,  in  various  conditions, 

366 
section  on,  359 

watery,  watery-mucous,  and  mu- 
cous, significance  of,  360 
Vomited  material  illnstrated,  365 
Vomiting,  act  of,  described,  358 

central,  diseases  in  which  it  oc- 
curs, 358 
due  to  round-worms,  380 
frequency  of,  359 
from  irritability  of  larynx,  590 
from  severe  coughing,  166 
from  uraemia,  440 
in  diseases  of  abdominal  organs 

other  than  the  stomach,  358 
induction    of,    when   contra-indi- 
cated, 342 
kinds  of,  clinically  distinguished, 

358 
of  use  in  obtaining  contents  of 

stomach,  341 
phenomena  associated  with,  359 
reflex,  358 
section  on,  358 
time  when  it  begins,  359 
ways  in  which  it  occurs,  358 


INDEX. 


699 


Vomiting,  when  it  occurs  in  nervous 

diseases,  578 
Vomitus    matutinus   potatorum,  359, 
361 
amount  of  vomit  in,  360 


WAGNEE,  E  ,  reference  to.  171 
Waldenburg,  reference  to,  164 
Wandering  kidney,  395 
diagnosis  of,  396 
differential  diagnosis  of,  397 
liver,  331 

signs  of,  324 
spleen,  335 

described,  336 
differential  diagnosis  of,  397 
"Wasting    diseases,    haemic    murmurs 
heard  in,  229 
significance  of,  34 
Water-brash  of  drunkards,  361 

-whistling  defined,  153 
Waxv  casts,  a  form  of  hyaline,  423 

illustrated,  423 
Weichselbaum,  rei'erence  to,  427 
Weigert,  reference  to,  185 
Weight,   loss  of,   a  sign  of  disease, 
23 
of  bodv,  increase  and  diminution, 

34,  35 
relation  to  height,  35 
Weil,    Handbook    of  Topographical 
Percussion,  quoted,  112 
-Luschka,  quoted,  78,  79 
quoted,  113,  122,  123,  125 
reference  to,  116,   121,  130,  132, 
133, 192,  206,  207,  259,  304,  306, 
312,  319,  321,  327,  332  (note), 
333,  336,  338,  393 
Wernicke,  reference  to,  552,  553,  555, 

556,  558,  601 
Westphal,  reference  to,  498,  499,  525, 

527 
Westphal's  view  of  tendon  reflexes, 

500 

Whispered  voice,  auscultation  of,  159 

Whiteblood-corpuscles  in  sputum,  176 

increased  proportion  of, 

to  red,  in  anaemia,  275 

in  urine  of  cystitis,  419 

normal  proportion  of,  to 

red,  278 
with  hsematoidin  needles, 
432 
corpuscles,  increase  of,  in  leukae- 
mia shown  by  microscope,  279 


White  kidney,   large,   fatty   casts  in 
urine  of,  423 
dropsy  with,  440 
form    of  epithelium    in 

urine  of,  421 
lipuria  in,  447 
Whooping-cough,  effect  of,  on  venous 
circulation,  263 
expansion  of  lungs  after,  136 
expiratory  bulging  in,  98 
microbe  of,  190 
phenomena  of,  described,  166 
relation  to  emphysema,  22 
severe  cough  of,  a  cause  of 

emphysema  of  skin,  56 
vomiting  in,  358 
Will,  conscious,  participation  in  co- 
ordination, 528 
Williams's   tracheal    tone  described, 

111,  121,  131,  132 
Willis,  circle  of,  461 
Wintrich,  reference  to,  104 
Wintrich's  change  of  sound  described, 

111,  132,  159 
Woillez's  cystometer,  163 
Wolff,  reference  to,  246 
Women  apt  to  conceal  disease,  20 
Word-blindness,  testing  for,  556 
-deafness,  55,  461 
defined,  552 
testing  for,  556 
the  condition  of  the  hearing 
must  be  determined  in,  573 
Worms,  a  cause  of  epileptiform  attacks 

in  children,  533 
Wrisberg,  cartilages  of,  591 
Writer's  cramp,  532,  561 
Writing,  an  acquired  faculty,  549 
centre  for,  557 
diagnostic  value  of  the  character 

of,  561 
disturbances  of  power  of,  549 
how  acquired,  549 
Wunderlich,  quoted,  65,  68,  69,  70 
Wunderlich's  table  of  temperatures,  61 


VANTHIN  crystals,  433 

YEAST  cells  in  sputum,  190 
fungus  in  urine,  important  when 
there  is  sugar,  428 
Yellow  atrophy  of  liver,  acute,  dimi- 
nution  of  phosphates 
in  urine  with,  435 


700 


INDEX. 


Yellow  atrophy  of  liver,  acute,  leucin 
and   tyrosin   in  urine 
of,  432 
acute,    urea   diminislied 

in,  434 
diminished  area  of  dul- 
ness  with,  331 
fever,    hsemato -jaundice    in,   47 
hemorrhage   of  stomach  in, 
362 


ZEISS'  apparatus  for  polarization, 
447 

reference  to,  175,  274,  281,  447 
Zenker,  reference  to,  179 
Ziehl,  reference  to,  187 
Ziemssen,  reference  to,  164,  302,  508, 

593,  594,  596,  598,  599 
Zimmerlin,  reference  to,  524,  525 
Zygoma,   what   palpation   above  and 

below  shows,  537 
Zygomatic  nerve  illustrated,  485 


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